英文病历模板.doc

英文病历模板 英文病历模板 PAGE 英文病历模板 Medical Records for Admisson Medical Number: 1247717 General information Name: Cai Chunwang Age: 47y Date of birth :1965. Sex: male Race: Han Nationality: China Marriage: married Occupation: worker Identification No. :42276 Address: Huanggang city ,Hubei Phone No.: Complainer of history: Cai Chunwang Reliability: Himself Date of record: Chief complaint: Pancytopenia for 2 year Present illness: The patient found Pancytopenia at 2011, and he used to be in hospital to take a physical examination which was considered into Myelodysplastic syndrome with a large probability . The patient had reexamined hemogram , with obvious pancytopenia .So he got into the hospital to do the Bone marrow cytology and Immune typing ,which showed that MDS had aggravated into AML .Now , he has no any bleeding spot in the skin ,without headache 、melena、stomachache and so on. The clinic made it “AML” to be treated in hospital. During the period of the illness, his mental state is bad ,with a fair appetite and sleep . The stool and urination are both normal, with a hyposthenia. Weight is the same as before. Past history: general situation is bad System review: Respiratory system: No. Circulatory system: No Alimentary system: No Genitourinary system: No Hematopoietic system: No Endocrine system: No Kinetic system: No Neural system: No Infectious history: Denied Allergic history:. No Operative history: He was once operated on an cholecystectomy. Tauma history: Denied. History of allergy: Denied . History of preventive inoculation] : the national plan for vaccination Personal history Menstrual history: Male Obstetrical history: No Marriage: married once. Family history:His father and mother are alive and healthy. Denies genetic and infectious diseases in his family. Physical examination T 37℃, P95 /min, R 20 /min, BP 124/78 mmHg. He i