医学英语病例书写样本（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 he had ate 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: Not clear.
Family history: His parents have both deads.
Physical examination

T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His 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. Superficial lymph nodes were not found enlarged.
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 150/min. Cardiac rhythm was not 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: Not examed.
Rectum: not exaned

Investigation
Blood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L
History summary

1. Patient was male, 80 years old
2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
3. No special past history.
4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. 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. No other positive signs.
5. investigation information:
  Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L

                Impression: upper gastrointestine hemorrhage
            Exsanguine shock