科研教学 > 医学英语
皮肤科英文查房手册连载(21):临床英文病历展示 
皮肤科医师之家       2013年8月12日        阅读数:673        字体:      


  Case1: 在这里我们学习一个英文病历来自上海市皮肤病医院。采用完全与我们目前中文病历格式一一对应的书写方式,由
Nallamothu, Padma医生修改审定。


  Medical Records for Admisson

  Medical Number: 00xxxxx

  General information

  Name: ZY

  Age: forty eight

  Sex: Female

  Race: Han

  Nationality: China

  Address: NO.xxx, HB Road, Shanghai.

  Tel:021-xxxxxxxx

  Occupation: Retired

  Marital status: Married

  Date of admission: Jul 3th, 2009

  Date of record: 3pm, Jul 3th, 2009

  Complainer of history: patient’s mother-in-law and herself

  Reliability: Reliable

  Chief complaint:

  An ulcer on the left leg with slight exudate and itch last for three years.

  Present illness:


  The patient got her left leg accidentally injured three years ago. But she didn’t ask for medication. A few days later, the trauma became an ulcer. So she went to the local hospital, where she was given some extermal cream everyday (unclear). But there seemed little effect after two weeks. The patient subsequently went to the Institute of Dermatology of Nanjing in 2008, diagnosed as
“trauma induced ulcer”. She was given Erythromycin orally and Lincomycin for external using. Nevertheless the edge of the 
lession became larger. The erythema and edma occurred around the ulcer, and she felt itchy. Then she was admitted to our 
resident department for the further treatment, diagnosed as “trauma induced ulcer and eczema”.


  Since the disease coming on, she had no chill, fever, chest pain or sore joints. The urinating was normal.

  Past history:

  The patient is healthy before. no history of infective diseases as “ tuberculosis”. history of preventive inoculation not in det. No operation history. No history of using particular drugs, no history of transfusio sanguinis and no history of contacting bad materials.

  Past history:

  Respiratory system: no history of cough, sputum, short of breath, chest pain, night sweeting, fever.

  Circulatory system: no history of palpitation, chest pain, short of breath, cough and hemoptysis, edema, syncope, dizziness.

  Alimentary system: no history of belching, sour regurgitation, abdominal distension, abd. pain, diarrhea, nausea and vomiting.


  Genitourinary system: no history of difficulty in micturition, frequency and rugency of micturition, painful micturition, 
abdominal pain, edema.


  Hematopoietic system: no history of fatigue, dizziness, palpitation, bleeding.


  Endocrine system: no history of palpitation, heat intolerance, excessive sweeting, polydipsia, edema, hand tremble, wasting 
and obesity.


  Kinetic system: No history of confinement of limbs, joint pain, numbness, claudication, paralysis.

  Neural system: no history of headache, coma, dizziness and vertigo, insomnia, hemiplegia, aphasia.

  Personal history:


  The patient was born in shanghai, She had not been to other place. She did not contact contaminated water. She didn’t 
smoked and didn’t drink. She had no history of unclean coitus.


  marrital and childbearing history: married, had a son who was healthy


  family history: Her father was well but suffered from hypertension. Her mother is health; others of his family had no the same 
sickness and genetic disease.


  Physical examination

  T 37.2℃, P 80/min, R 17/min, BP 130/80mmHg.

  general condition: mental state is good, well –developed, well –nourished, active position, cooperative in the examination, well answered.


  Mucocutaneous : Her face was cadaverous and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema.



  lymph nodes: superficial lymph nodes of pre(post)-auricular , occipital submental , submaxillary anterior (posterior) cervical, supraclavicular, axillary top , inguinal can not be palpated.


  Head

  Cranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.


  Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No
tenderness in mastoid area. Auditory acuity was normal.


  Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.


  Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. 
Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and 
indirect pupillary reactions to light were existent.


  Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.

  Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.

  Chest


  Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor 
widened. No tenderness.


  Thorax: Symmetric bilaterally. No deformities.

  Breast: Symmetric bilaterally.


  Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was 
heard. No wheezes. No rales.


  Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs.


  Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not 
seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No 
vascular murmurs.


  Extremities: No articular swelling. Free movements of all limbs.

  Neural system: Physiological reflexes were existent without any pathological ones.

  Genitourinary system and rectum: normal.

  Professional examination: The interdigit of both feet was dry with peeling. The teleinterdigit was blanch. Both extremity had some dark red spot on which there was several blisters as different size .The blain of blisters was not easily to broke.

  Impression:1, trauma induced ulcer 2, eczema

  Signature:WYF