儿科英文病历模板

儿科英文病历模板

Medical Records for Admisson

Medical Number: 696235

General information

Name: Zhang Yi

Age: thirteen

Sex: Female

Race: Han

Nationality: China

Address: NO.23, Yunchun Road,

Jiefang Rvenue, Hankou, Hubei.

Tel: 85763723

Parents Name: father Zhang Hesheng Mother Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s mother Reliability: Reliable Yang

Chief complaint: Pharyngalgia and fever for four days. Present illness:

The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there she received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown”

Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.

Past history

The patient is healthy before.

No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy history of

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