呼吸科英文病历_皮肤科病历英文

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ENGLISHCASE700756(Respiratory department)

----------------------------Name: Liyuzhen `Age:42 yearsSex: FemaleRace: HanOccupation: Free occupationNationality: ChinaMarried status: married

Addre: Qianjing Road No.16, Wuhan Hankou.thDate of admiion: July 26, 2001

thDate of record: July 26, 2001

Complainer of history: Patient herselfReliability: Reliable----------------------------Chief Complaint: Cough and dyspnea for 2 days.Present illne:

Two days ago the patient suddenly started to cough and feel

dyspnea after having a bath.It became more and more serious, so the patient went adjacent hospital.After some treatment, her symptoms were still.So she came to our hospital.Since its coming on, she never felt headache, nausea, bellyache and her phlegm was few.Her spirit,sleep,appetite were normal.stool and urine were

normal, too.----------------------------PastHistory:

General health status: normal

Operation history: thyroidectomy.Infection history: No history of tuberculosis or hepatitis.Allergic history: allergic to a lot of drugs such as sulfanilamideTraumatic history: No traumatic history

----------------------------Systemreview

Respiratorysystem: No history of repeated pharyngodynia, chroniccough, expectoration, hemoptysis, asthma, dyspneaor chest pain.Circulation system: No history of palpitation, hemoptysis, legsedema, short breath after sports, hypertension,precordium pain or faintne.Digestive system: No history of low appetite, sour regurgitation,belching, nausea, vomiting, abdominal distension,abdominal pain, constipation, diarrhea, hemaptysis,melena, hematochezia or jaundice.Urinary system: No history of lumbago, frequency of urination,urgency of urination, odynuria, dysuria, bloodyurine, polyuria or facial edema

Hematopoietic system: No history of acratia, dizzine, gingival

bleeding, nasal bleeding, subcutaneous bleeding

or ostealgia.Endocrine system: No history of appetite change, sweating, chilly

exceive thirst, polyuria, hands tremor, character

alternation, obesity, emaciation, hair change, pig-

mentation or amenorrhea.Kinetic system: No history of wandering arthritis, joint pain,red swelling of joint, joint deformity, muscle pain

or myophagism.Neural system: No history of dizzine ,headache, vertigo, in-

somnia, disturbance of consciousne, tremor, conv-

ulsion, paralysis or abnormal sensation.---------------------------

Personal History:

She was born in Hubei.She never smokes and

Drinks.No exposurehistory to toxic substances,and infected water.Her menstruation was normal.LMP:23/7,2001----------------------------

Family History:

Her parents are living and well.No congenital

disease in her family.----------------------------

PhysicalExamination

Vital signs:T 36.6`C , P 80/min, R 22/min, BP120/80mmHg.General inspection: The patient is a well developed, well nou-

rished adult female apparently in no acute distre,pleasant and cooperative.Skin:Normally free of eruption or unusual pigmentation.Lymphnodes: There are no swelling of lymphnodes.Head: Normal skull.No baldne, noscars.Eyes: No ptosis.Extraocular normal.Conjuctiva normal.The

Pupils are round, regular, and react to light and ac-

Commodation.Ears: Externally normal.Canals clear.The drums normal.Nose: No abnormalities noted.Mouth and throat: lips red, tongue red.Alveolar ridges normal.Tonsils atrophil and uninfected.Neck: No adenopathy.Thyroid palpable,but not enlarged.No

Abnormal pulsations.Trachea in middle.Chest and lung: Normal contour.Breast normal.Expansion equal.Fremitus normal.No unusual areas of dullne.Diaphr-

agmatic position and excursion normal.No abnormal br-

eath sound.No moist rales heard.No audible pleural fric-

ion.There are lots of rhonchi rales and whoop can be heard

thHeart: P.M.I 0.5cm to left of midolavicular line in 5 inter-

Space.Forceful apex beat.No thrills.No pathologic

heart murmur.Heart beat 80 and rhythm is normal.Abdomen: Flat abdomen.Good muscle tone.No distension.No v-

isible peristalsis.No rigidity.No ma palpable.Tenderne(-), rebound tenderne(-).Liver and spleen

are not palpable.Shifting dullne(-).Bowl sounds

normal.Systolic blowing murmur can be heard at the

right side of the navel.Extremities: No joint disease.Muscle strength normal.No ab-

normal motion.Thumb sign(+).Wrist sign(+).Neural system:Knee jerk(-).Achilles jerk(-).Babinski sign(-).Oppenheim sign(-).Chaddock sign(-).Conda sign(-).Hoffmann sign(-).Neck tetany(-)Kernig sign(-).Brudzinski sign(-).Genitourinary system: Normal.Rectum: No tenderne------

Out-patient department data:

No----------------------------

Historysummary

1).Li Yuzhen, female, 42y.2).Cough and dyspnea for 2 days

3).PE: T 36.6`C, P 80/min, R 22/min, BP120/80mmHg.superficial

nodes were not palpable.Normal vision.Upper palate haunch-

-uped.HR: 80bpm, rhythm is normal.There are lots of rho-

nchi rales and whoop can be heard.Flat abdomen, Tenderne

(-),rebound tenderne(-).Liver and spleen are not pal-

pable.Shifting dullne(-).Bowl sounds normal..4).Outpatient data: see above.----------------------------

Impreion: Bronchial asthma

Signature:He Lin 95-10033