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英文病历书写范例（内科）??
Medical?Records?for?Admisson
Medical?Number:?701721?
General?information??
Name:?Liu?Side?
Age:?Eighty?
Sex:?Male?
Race:?Han?
Nationality:?China?
Address:?NO.35,?Dandong?Road,?Jiefang?Rvenue,?Hankou,?Hubei.?
Tel:?857307523?
Occupation:?Retired?
Marital?status:?Married?
Date?of?admission:?Aug?6th,?2001?
Date?of?record:?11Am,?Aug?6th,?2001?
Complainer?of?history:?patient’s?son?and?wife?
Reliability:?Reliable??
Chief?complaint:?Upper?bellyache?ten?days,?haematemesis,?hemafecia?and?unconsciousness?for?four?hours.?
Present?illness:??
The?patient?felt?upper?bellyache?about?ten?days?ago.?He?didn’t?pay?attention?to?it?and?thought?hehadate?something?wrong.?At?6?o’clock?this?morning?he?fainted?and?rejected?lots?of?blood?and?gore.?Then?hemafecia?began.?His?family?sent?him?to?our?hospital?and?received?emergent?treatment.?So?the?patient?was?accepted?because?of?“upper?gastrointestine?hemorrhage?and?exsanguine?shock”.?Since?the?disease?coming?on,?the?patient?didn’t?urinate.??Past?history?
The?patient?is?healthy?before.?
No?history?of?infective?diseases.?No?allergy?history?of?food?and?drugs.??
Past?history?Operative?history:?Never?undergoing?any?operation.?Infectious?history:?No?history?of?severe?infectious?disease.?Allergic?history:?He?was?not?allergic?to?penicillin?or?sulfamide.?Respiratory?system:?No?history?of?respiratory?disease.??Circulatory?system:?No?history?of?precordial?pain.?Alimentary?system:?No?history?of?regurgitation.?
Genitourinary?system:?No?history?of?genitourinary?disease.?
Hematopoietic?system:?No?history?of?anemia?and?mucocutaneous?bleeding.?Endocrine?system:?No?acromegaly.?No?excessive?sweats.??Kinetic?system:?No?history?of?confinement?of?limbs.?Neural?system:?No?history?of?headache?or?dizziness.?Personal?history?
He?was?born?in?Wuhan?on?Nov?19th,?1921?and?almost?always?lived?in?Wuhan.?His?living?conditions?were?good.?No?bad?personal?habits?and?customs.?
Menstrual?history:?He?is?a?male?patient.?Obstetrical?history:?No
?
Contraceptive?history:?
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