英文大病历文档格式.docx

1、Date of admission: February 28 2003 Date of history taking :February 28 2003Narrator: the patient Reliability of the history: reliable The History Chief Complaint: lumbago for 2 years with weakness ,numbness in lower limbs, more severe 2 months.Present Illness:2 years ago ,after working ,the patient

2、 always felt lumbago, sometimes referred pain at the hip and lower extremities,mainly at the dorsal side.and the left lower limb was more severe. At the same time he felt weak and numb at lower limbs, also more severe in the left side. No muscle atrophy, no abnormal of stool and urine. No temperatur

3、e abnormal or color changes in the local skin. No nails damaged. Then the patient went to the hospital in his town, and had a X-ray examination, shown hypertrophy in the lumbar vertebrae., given some drugs for pain-control. After having some drugs and more rest, the symptoms lightened. But 2 months

4、ago ,without significant causes,the symptoms became more severe. The lumbago often made him sleepless at nights. And he can only walk 500 meters without a break. his left lower limb felt numb and weak.Having the drugs and rest both can not ease the symptoms. So he came to our hospital for advanced d

5、iagnosis and treatment. Since the disease, no changes in consciousness,body temperature, appetite, body weight .and normal of stool and urine. Past history: the patient had a history of high intensive working for about 10 years. No history of chronic diseases like hypertension, CAD and mellitus diab

6、etics. No history of hepatitis or AIDS , tuberculosis .No history of trauma and operation. No history of hypersensitivity of any drug or food.Review of Systems:Respiratory system: no history of chronic cough , expectoration, hemoptysis , chest pain , or short of breath.Circulation system: no history

7、 of dyspnea or edema at the lower limbs. No history of palpitation or chest pain. No dizziness, headache, No history of hypertension.Digestive system: no history of anorexia, abdominal distention, regurgitation. No nausea and vomiting. No history of constipation , diarrhea ,melena and so on.Urogenit

8、al system: no history of swollen eyelids or lumbago. No frequent micturition, urgency of micturition or urodynia. No dysuria ,hematuria or retention and incontinence of urine .no history of acute or chronic nephritis.Hemopoeltic system: No pallid countenance ,weakness,dizziness , daze ,tinnitus. No

9、history of bleeding and repeated infections. No history of enlargement of liver and spleen.Metabolic and Endocrine system: no abnormal cold or hot feeling, hidosis ,headache weakness,impaired vision,polyphagia ,polyuria ect.normal distributed hair.no change of temper and intelligence.Nervous system:

10、 No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal sensation or motion. No change of personality .no mania ,depression or hallucination.Motor system: lumbago and limitation of movement for 2 years. weakness and numbness at lower limbs, the left more severe. No spasm, at

11、rophy or palalysis. No joint red swollen, hot ,pain or limitation of motion. No trauma or fracture.Personal history : born in her native place and living in Tianjin. No history of exposure to poison.No habits of drinking or smoking.Marital History:. Married at 24 years old and having a child. the ch

12、ild and his wife both health.Family history: denying the family history of any heredity diseases ,or MD, CAD, hypertension ect. Physical Examination Temperature: 36.5C pulse rate: 72/min respiratory rate: 18/min blood pressure:130/80mmHgGeneral appearance : normal development and medium in nourished

13、 ,no abnormal consciousness, good corporation in examination. Free position. Skin and mucous membrane : No pallid , cyanosis, and jaundice . no abnormal pigmentation and depigmentation . no erythma annulare, petechia and spider angioma. Normal elasticity of skin, no edema.Superficial lymph nodes: no

14、 enlargement of the superficial lymph nodes.Head and its organs:Skull: no deformity, tenderness or mass. Evenly distributed hair with black color and shine.Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids. No pallor, granules ,follicles pectechiae of conjunctivae . tr

15、ansparent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization. No exophthalmos or enophthalmos.free motions of the eye balls in any direction. Equal and round pupils at both sides with diameter 4mm, normal and active direct and indirect light reflexs,normal accommodation and conve

16、rgence reflexes. Vision , visual field and eyegroud not examined.Ears:no deformity .no abnormal secretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.Nose: no deformity. No deviation of septum nasi. No ala flutter. No edema ,abnormal secretion ,and c

17、ongestion of the membrane . good ventilation. No tenderness in any paranasal sinuses.Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth, no caries. No bleeding or congestion ,lead line in gums. Thin and sl

18、ight yellow fur coated on the tongue ,with normal in motion. No redness and congestion in pharynx ,no deviation of uvulae. No edema in tonsils.Neck: symmetry . no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins. No rigidity .no enlargement of thyroid glands ,

19、and the trachea in the centeral position. No murmur. Negative of hepatojugular reflux.Chest: symmetry. No deformity. No barrel chest ,pigeon chest or funnel chest. No tenderness over the chest .the thoracic respiration present. R 18/min, symmetry in both sides. Symmetry and no abnormality of the 2 b

20、reasts.Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration. Respiratory movement equal in both sides and regular . no dyspnea or three concave sign.Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus. No pleural fri

21、ction fremitus . no subcutaneous crepitation.Percussion: resonance in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th ,8th ,10th on midclavicular ,midaxillary,midcapular line respectively. The movement of the lower margin of the lungs: 6 cm.Auscultation: clear

22、 of vesicular breathing sounds all over the lung fields. No moist rales or rhonchis .normal of vocal resonance. No pleural friction sound.Heart:Inspection: no precordial bulging. Apical impulse in the 5th ICS 1cm inside of left midclavicular line with an area of 2 cm in diameter. apical impulse and

23、its area as that in inspection. Regular ,normal intensity. No pericardial friction rubs or thrill. relative cardiac dullness shown as follows:Right （cm）ICS Left （cm）24367 The distance between the left midclvicular line and the midsternal line is 8cm. HR 72/min with regular rhythm, heart sounds clear

24、 and intensive . no murmurs at any auscultation area of the valvula. No pericardical friction sound.Radial arteries: pulse rate 85/min, with regular rhythm, equal in both sides, normal intensity .Perivascular signs: no capillary pulsation, water hammer pulse ,pistol-shot sounds and Duroziezs murmur

25、. no pulse deficit, and pulse alternant. Abdomen: symmetry. No bulge abdomen ,abdominal distention .normal abdominal respiration. No visible gastrointestinal waves. No varicosity , scar ,petechia at the abdominal Skin. soft, no tenderness and rebounding tenderness, no tightened abdominal wall. No pa

26、lpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphys sign.Kidneys: not palpable. No tenderness in the any site of kidneys or ureters. Spleen:Appendix: no tenderness at the Mcburneys site. tympany in all over the abdomen, no shifting dullness. No percussive pain of liver and

27、 spleen. The upper margin of liver at the 5th ICS in the right midcalvicular line normal borhorygmus, 4/min, no murmur of vessels. No friction rubs .Anus and rectum: not examined.Spine: no lordosis, kyphosis, or scoliosis. tenderness and punching tenderness at the level of L3-L5. Limitation of movem

28、ent, especially anteflextion. No changes in the local skin.Extremities: symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.myodynamia of left lower limb in 4th grade and right lower limb in 5-th grade. Details in the special co

29、ndition.Nerve system:numbness in lower limbs ,more severe in left side. Normal sensation.at other place. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinskis （+_）oppenheims,chaddocks,gordons negative. No patellar or ankle clonus.La

30、boratory findings:Blood routine: WBC 7.3*10 ,N 0.65, L 0.35,Hb 141g/l .RBC 4.38*1012/l ,plt 238*10/l.X-ray: hypertrophy of lumbar vertebrae.MRI : the results not gotten.Special condition: no lordosis, kyphosis, or scoliosis of spine. tenderness and punching tenderness at the level of L3-L5. Limitati

31、on of movement, especially anteflextion. No changes in the local skins. extrmities symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.Muscular tension of left lower limb in 4th grade and right lower limb in 5-th grade. Sensation in left lower limb decreased. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinskis （+_）oppenheims,chaddocks,gordons n