英文病历样本

GeneralinformationNameAgeSexRaceNationalityAddressOccupationMaritalstatusDateofadmissionDateofrecordComplainerofhistoryReliability:ReliableChiefcomplaintThepatienthasacoughproducingthickrustysputumandahighfeverthatisaccompaniedbyshakingchills.Hehasarightchestpainwhenbreathing.HistoryofpresentillnessThepatienthashadacoldafterswimminginthecoldwaterrecently.Hehadacoughwiththickrustysputum.Hehadshakingchillsandfeltachestpainontherightside.Hesawadoctor.Aweekafter,hethoughthewasoveritanddidn’tpayattentiontoit,wentswimmingagain.Nowtheconditionismoreserious.Hehasahighfeverwith39℃thatisaccompaniedbyshakingchills.Hehasabadcoughwithno-bloodsputum.Whenhetakesadeepbreath,itevenhurts.PastmedicalhistoryThepatientishealthbefore.Nohistoryofinfectivedisease.Noallergyhistoryoffoodanddrugs.Nooperativehistory.Nodiseasehistoryinothersystem.PersonalhistoryHewasborninXXXonXXXXandalmostalwayslivesinXXX.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Heisamalepatient.Familyhistory:Hisparentsarebothalive.PhysicalexaminationGeneral:TPRBPWH.Thepatientisawell-developed,well-nourishedadultmale.HEENT:PERRL,EMOI,smalloralaperture.Neck:JVPtoangleofjaw,2+carotidpulses,fullrangeofmotion.Cardiac:RRR,normalS1,S2,distantheartsounds.Chestwall:Nosubcutaneousemphysema.Notenderness.Thorax:Symmetricbilaterally.Breast:Symmetricbilaterally.Lungs:Respiratorymovementisbilaterallyasymmetricwiththefrequencyof24/min.Wecanhearcoarsebreathingwhenlisteningtoaportionofthechestwithastethoscope.Therearemoistralesonbilateralinferiorlung.Heart:Borderoftheheartisnormal.Heartsoundsarestrongandnosplitting.Rate150/min.Nopathologicalmurmurs.Abdomen:Flatandsoft.Noabdominalwallvaricose.Thereisnoreboundtendernessonabdomenorrenalregion.Liverandspleenareuntouched.Skin:Nopigmentation.Nopittingedema.Noskineruption.Extremities:Noarticularswelling.Alllimbscanfreemove.Genitourinarysystem:Notexamed.Rectum:Notexamed.Neuralsystem:Physiologicalreflexesareexistentwithoutpathologicalones.InvestigationChestX-ray:Lamellarshadowcanbeseeninmiddleandinferiorlobeofrightlung.Therightlungisseriouslyinfected.Thevolumeofusefullungisreducedbecauseofthecollectionoffluidaroundthelung.