眼科英文病例模板(myself)(可编辑)

眼科英文病例模板（myself）

Medical Records for AdmissonMedical Number: 701721

General information

Name: Liu Xiaojing

Age:56

Sex: Male

Nationality: China

Motherland:Chongqing

Address:

Occupation: worker

Marital status: Married

Date of admission:

Date of record:

Complainer of history: himself

Reliability: Reliable

Chief complaint:

Present illness: Contain: main symptoms e g. The patient felt…; symptoms for differential diagnosis e g. without vomiting;examination and therapeutic proceduree g. drugs、surgery;Is he going well or worse?; So why he came to our hospitale g. for further treatment;the diagnosis in outpatient clinicPast history:Contain: Is the patient healthy before? History of infective diseasee g. hepatitis B,TB ; History of HBP、DM、CHD; History of trauma and surgery; Allergy history of food and drugse g. penicillin、sulfamide; History of blood transfusion; History of vaccinatione g. he was inoculated according to the national plan

Systems review:

Head and neck: no history of deaf, tinnitus, vertigo, headache, epistaxis, gum hemorrhage and hoarseness.

Respiratory system: No history of respiratory diseaseCirculatory system: No history of precordial pain.

Alimentary system: No history of regurgitation.

Genitourinary system: No history of genitourinary diseaseHematopoietic

system: No history of anemia and mucocutaneous bleedingEndocrine system: No acromegaly. No diabetes mellitusKinetic system: No history of confinement of limbsNeural system: No history of headache or dizziness.

Personal history:

e g. He was born in Chongqing on Nov 19th, 1921 and lived in Chongqing. His living conditions were good. He has never been to malaria, paragonmiasis, and schistosoma prevalent areas. He works as worker, and has college education. He never smokes, drinks, or has any drug abuses.No bad personal habits and customs.

Menstrual and Obstetrical history: He is a male patient.

Family history: No history of special hereditary disease and infective disease are found in his family. His parents are both healthy.

Physical examination

T 36.5℃,P 80/min,R 20/min, BP 100/60mmHg He is well developed and moderately nourished. Active position. His consciousness was clear. His face was sanguine 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 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:The details is in the “special examination” Mouth: Oral mucous membrane was smooth, no ulcer can be seen. Tongue was in midline. Pharynx wasn’t congestive. Tonsils were not enlarged

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

ChestChestwall: 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 20/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 imum 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: Not examed.

Rectum: not exanedEye exam Right eye Left eye

Visual Acuity:

Visual acuity - uncorrected: OD: 20/200OS: 20/100

Refraction:

Lenses - final:

OD: +6.00 +4.50 X 90 Prism 4.00 →20/100; OS: +6.00 +3.50 X 125 Prism 4.00 →20/20 IOP: 10mmHg10mmHg

Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.

Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet.

Conjunctiva:

Cornea:

Anterior angle chamber:

Pupils: Pupil exam reveals round and equally reactive to light and accommodation.

Iris:

Visual Fields: Confrontation VF exam reveals full to finger confrontation OU.

Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance.

Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber.

Lens: Bilateral lenses reveals transparent lens that is in normal position.

Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas

reveal normal color,

contour, and cupping.

Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas

reveal normal reflex and color.

Test Results: No tests to report at this time

Impression: Eye and vision exam normal.

Plan: Return to clinic in 12 months.

Investigation

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

History summary

Patient was male, 80 years old

Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hoursNo special past history.

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.

investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L

Impression:

upper

gastrointestine

hemorrhageExsanguine

shockSignature: He Lin 95-10033