英文病历示范

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1、History taking of coughPatient Name: Mrs. PennyAge: 35History conducted by: Doctor ZhangHistory conducted on: 31/08/2014 4:00pm. Source: The patient gives her own history and appears to be a reliable sourceChief complaint: Productive coughHistory of present illnessMrs. Penny is a 40-year-old yellow

2、Chinese female who works in No.1 middle school as a teacher. She has been noticing worsening cough for 1 week, which is from dry to be with white sputum, and the volume of sputum is about 1 tea spoon per time. There is no accompanying chest pain or any other symptoms. The cough is relatively constan

3、t throughout the day and night but does vary in severity and it is severest right after waking up in the morning. Changing body positions, especially standing up, worsens the cough. Mrs. Penny finds no ways to relief it. She had a cold and a 39C fever one week ago, and then started to cough as a res

4、ult. She has been taken several days off due to the cough and sought for another doctors help in a community hospital 3 days ago, but those prescribed penicillin and antitussive didnt work. Past medical history1. Mrs. Penny once had tonsillitis at 6 years old, accepting penicillin with dose unknown.

5、2. At 35 years old, she received appendectomy after appendicitis without blood transfusion.3. She has been experienced chronic cough for 5 years, which is associated with cold whether especially winter days. And the cough will last for 3 months each year. She didnt look for any treatments or drugs.M

6、edicationsShe took penicillin 3 days ago. No known drugs allergies.整理为word格式Family historyMrs. Pennys son is 12 years old and he is healthy.Social HistoryMrs. Penny is a Chinese teacher in No.1 middle school. She is married and has a 12-year-old son. She denies past or present tobacco and alcohol us

7、e.Review of systemsGeneral-as is indicated in the history of present illness, no fevers or chills; appetite not assessed; denies fatigue, malaise, weight lossSkin denies rashes and skin lesions anywhere on her body.HEENT: Head Denies headache; denies dizziness or syncope Ears denies difficulty or ch

8、anges in her hearing, denies tinnitus Eyes denies problems or changes in her vision; denies blurred vision; denies seeing spots Nose Denies congestion or rhinorrhea Throat denies dysphagia or sore throatCardiovascular denies chest pain; denies palpitationPulmonary denies shortness of breath, endorse

9、s cough with white sputumGastrointestinal denies abdominal pain; denies diarrhea or constipation; denies bloody bowel movementGenitourinary denies dysuria; denies increased frequency or urgency of urinationNeurologic denies numbness and tingling; denies paresthesiasMusculoskeletal denies any muscle

10、or joint painHematopoietic denies easy bruisingPsychiatric denies depression, anxiety, mental disturbance, difficulty sleeping, suicidal ideation, hallucinations, paranoiaEndocrine denies polyuria, polydipsia, polyphagia, weight change, heat or cold intoleranceHeme/Lymphatic: denies easy or excessiv

11、e bruising, history of blood transfusions, anemia, bleeding disorder, adenopathy, chills, sweatsAllergic/Immunologic: denies urticarial, hay fever, frequent urinary tract infections; denies HIV high risk behaviors整理为word格式References:1. https:/www.med.unc.edu/medselect/resources/sample-notes/sample-write-up-12. http:/clerkship.medicine.ufl.edu/portfolio/patient-care/write-ups/sample-write-up/3. https:/en.wikipedia.org/wiki/Review_of_systems4. https:/www.med.unc.edu/medselect/resources/sample-notes5.6. 7. 友情提示：本资料代表个人观点，如有帮助请下载，谢谢您的浏览！8. 9.10. 11.12.整理为word格式