病历英文格式

A Sample of Complete History PATIENT'S NAME: Mary Swan CHART NUMBER: 660518 DATE OF BIRTH:10-5-1993 SEX: Female DATE OF ADMISSION: 10-12-2000 DATE OF DISCHARGE: 10-15-2000 Final Discharge Summary Chief Complaint: Coughing, wheezing with difficult respirations. Present Illness: This is the first John Hopkins Hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to Tedral or cough medicine. The wheezing progressed and the child was taken to John Hopkins Hospital Emergency Room where the child was given epinephrine and oxygen. She was sent home. The patient was brought back to the ER three hours later was admitted. Past History: The child was a product of an 8.5-month gestation. The mother had toxemia of pregnancy. Immunizations: All. Feeding: Good. Allergies: Chocolate, dog hair, tomatoes. Family History: The mother is 37, alive and well. The father is 45, alive and well. Two sibs, one brother and one sister, alive and well. The family was not positive for asthma, diabetes, etc. Review of Systems: Negative except for occasional conjunctivitis and asthma. Physical Examination on Admission: The physical examination revealed a well-developed and well-nourished female, age 7, with a pulse of 96, respiratory rate of 42 and temperature of 101.0℉. She was in a mist tent at the time of examination. Funduscopic examination revealed normal fundi with flat discs. Nose and throat were somewhat injected, particularly the posterior pharynx. The carotids were palpable and equal. Ears were clear. Thyroid not palpable. The examination of the chest revealed bilateral inspiratory and expiratory wheezes. Breath sounds were decreased in the left anterior lung field. The heart was normal. Abdomen was soft and symmetrical, no palpable liver, kidney, or spleen. The bowel sounds were normal. Pelvic: Normal female child. Rectal deferred. Extremities negative. Impression: Bronchial asthma, and pharyngitis. Laboratory Data: The white count on admission was 13,600 with hgb of 13.0. Differential revealed 64 segs and 35 lymphs with 3 Eos. Adequate platelets. Sputum culture and sensitivity revealed Alpha hemolytic streptococcus sensitive to Penicillin. Chest x-ray on admission showed hyperaeration and prominent bronchovascular markings. The child was started on procaine Penicillin 600,000 unites IM q.d in accordance with the culture and sensitivity of the sputum. Hospital Course: The child was given Penicillin IM as stated above. Ten drops of Isuprel were added to the respirator every 2 hours. The patient improved steadily. She took her diet well. She was discharged on 10-15-2000 in good condition. Operation procedure: none Condition on discharge: Improved Diagnosis: Asthma. Pharyngitis. Possible right upper lobs pneumonia.

检查：PE ；诊断 imp；处理 Rx