Medical case writing 201503
医学题目模板英语作文
医学题目模板英语作文英文回答：Medical Case History Template。
Patient Information。
Name:Age:Sex:Date of Birth:Medical Record Number:Reason for Visit:History of Present Illness。
Describe the patient's current symptoms in detail, including:Onset: When did the symptoms begin?Duration: How long have the symptoms lasted?Character: Describe the nature of the symptoms, such as pain, discomfort, or functional impairment.Location: Where are the symptoms located?Severity: Rate the severity of the symptoms on a scale of 1 to 10.Palliating and aggravating factors: Identify any factors that make the symptoms better or worse.Past History。
Medical history: List any previous medical conditions,surgeries, or hospitalizations.Surgical history: Describe any previous surgeries, including the date, type of surgery, and any complications.Immunization history: Record the patient's immunization status for common childhood vaccines.Allergies: Note any known allergies to medications, food, or environmental substances.Medications: List all current medications, including the name, dose, frequency, and route of administration.Family History。
医学病例报告英语作文
医学病例报告英语作文Title: Medical Case Report: Management of Chronic Hypertension in a Middle-aged Female Patient。
Abstract:This case report discusses the presentation, diagnosis, and management of chronic hypertension in a middle-aged female patient. The patient, Mrs. X, presented with a history of hypertension and was experiencing persistent elevated blood pressure despite lifestyle modifications and medication adherence. Through a comprehensive assessment, including medical history, physical examination, and diagnostic tests, the patient was diagnosed with chronic hypertension. The management approach involved pharmacological intervention, lifestyle modifications, and regular monitoring. This case highlights the importance of tailored treatment strategies and multidisciplinary care in managing chronic hypertension effectively.Introduction:Chronic hypertension, characterized by persistently elevated blood pressure levels, is a significant public health concern globally. It predisposes individuals to various cardiovascular complications, including stroke, heart failure, and renal dysfunction. This case report focuses on the management of chronic hypertension in a middle-aged female patient, emphasizing the importance of individualized treatment plans to achieve optimal blood pressure control and reduce the risk of associated complications.Case Presentation:Mrs. X, a 55-year-old female, presented to the clinic with a chief complaint of persistently elevated blood pressure readings despite adherence to antihypertensive medication. She reported a history of hypertension for the past ten years and a family history of cardiovascular diseases. On physical examination, her blood pressure was consistently elevated, averaging around 160/100 mmHgdespite being on a combination therapy of angiotensin-converting enzyme (ACE) inhibitor and diuretic.Diagnostic Assessment:Given the patient's history and physical examination findings, further diagnostic workup was pursued to assess the extent of target organ damage and potential secondary causes of hypertension. Laboratory investigations,including renal function tests, lipid profile, and electrolyte levels, were within normal limits. An electrocardiogram (ECG) revealed left ventricular hypertrophy, indicative of long-standing hypertension. Additionally, a renal ultrasound ruled out renal artery stenosis as a secondary cause of hypertension.Diagnosis:Based on the clinical presentation, diagnostic findings, and exclusion of secondary causes, Mrs. X was diagnosedwith chronic primary hypertension. The diagnosis was supported by her longstanding history of hypertension,family history of cardiovascular diseases, and evidence of target organ damage on ECG.Management:The management approach for Mrs. X's chronic hypertension involved a combination of pharmacological therapy and lifestyle modifications. Considering her persistent elevation in blood pressure despite the current medication regimen, the treatment plan was adjusted. A calcium channel blocker (amlodipine) was added to her existing therapy to achieve better blood pressure control. Furthermore, Mrs. X was counseled on dietary modifications, including a low-sodium diet and increased consumption of fruits and vegetables. She was also encouraged to engage in regular physical activity and weight management.Follow-up and Monitoring:Mrs. X was scheduled for regular follow-up visits to monitor her blood pressure response to the adjusted treatment regimen and assess for any adverse effects ofmedication. Additionally, she was advised to monitor her blood pressure at home using a digital blood pressure monitor and maintain a record for review during follow-up visits. Laboratory investigations, including renal function tests and electrolyte levels, were scheduled periodically to monitor for potential medication-related complications.Outcome:With the adjusted treatment regimen and adherence to lifestyle modifications, Mrs. X demonstrated significant improvement in blood pressure control. Subsequent follow-up visits showed a gradual reduction in her blood pressure readings, with values consistently below 140/90 mmHg. Repeat ECG performed six months later showed regression of left ventricular hypertrophy, indicating improvement in cardiac function. Mrs. X reported improved quality of life and compliance with the treatment plan.Discussion:This case illustrates the challenges encountered inmanaging chronic hypertension, particularly in patientswith resistant hypertension despite medication adherence.It underscores the importance of a comprehensive diagnostic approach to identify underlying causes and assess target organ damage. Individualized treatment strategies,including pharmacological therapy tailored to the patient's needs and preferences, are essential in achieving optimal blood pressure control. Furthermore, lifestylemodifications play a crucial role in hypertension management and should be integrated into the treatment plan. Multidisciplinary collaboration involving physicians, nurses, pharmacists, and allied healthcare professionals is vital in providing holistic care to patients with chronic hypertension.Conclusion:Effective management of chronic hypertension requires a multidimensional approach involving pharmacological therapy, lifestyle modifications, and regular monitoring. This case report highlights the successful management of chronic hypertension in a middle-aged female patient throughtailored treatment strategies and collaborative care. By addressing individual patient needs and optimizing blood pressure control, healthcare providers can mitigate the risk of cardiovascular complications and improve patient outcomes in individuals with chronic hypertension.。
医学英语三级作文
医学英语三级作文Medical English Level 3 Writing: The Importance of Medical Research。
Medical research plays a crucial role in the advancement of healthcare and the improvement of patient outcomes. It is through research that new treatments and therapies are developed, leading to better patient care and ultimately, saving lives. In this essay, we will explore the importance of medical research and its impact on the field of medicine.First and foremost, medical research is essential for the development of new treatments and therapies. Through research, scientists and healthcare professionals are able to identify new drugs, medical devices, and treatment protocols that can improve patient outcomes. For example, the development of targeted therapies for cancer has revolutionized the way we treat the disease, leading to better survival rates and improved quality of life forpatients. Without medical research, these advancements would not have been possible.In addition to developing new treatments, medical research also plays a critical role in understanding the underlying causes of diseases. By studying the mechanisms of disease, researchers can identify new targets for treatment and develop more effective interventions. For example, research into the genetic basis of certain diseases has led to the development of personalized medicine, where treatments are tailored to an individual's genetic profile. This has the potential to revolutionize the way we treat a wide range of diseases, from cancer to cardiovascular disease.Furthermore, medical research is essential for improving patient safety and the quality of healthcare delivery. Through research, healthcare professionals are able to identify best practices and develop guidelines for the management of various diseases and conditions. This ensures that patients receive the most effective and safest care possible, leading to better outcomes and reducedhealthcare costs. For example, research into infection control practices has led to the development of guidelines that have significantly reduced the incidence of hospital-acquired infections, improving patient safety and reducing healthcare costs.Moreover, medical research is essential for advancing our understanding of the human body and the mechanisms of disease. Through research, scientists are able to unravel the complex processes that underlie health and disease, leading to a deeper understanding of the human body and how it functions. This knowledge is essential for the development of new treatments and therapies, as well as for the prevention of disease. For example, research into the immune system has led to the development of new immunotherapies for cancer, which harness the body's own immune system to fight the disease.In conclusion, medical research plays a crucial role in the advancement of healthcare and the improvement ofpatient outcomes. Through research, new treatments and therapies are developed, our understanding of disease isadvanced, and patient safety and the quality of healthcare delivery are improved. It is essential that we continue to support and invest in medical research, as it has the potential to revolutionize the way we treat and prevent disease, ultimately leading to better patient care and improved public health.。
医患纠纷英文作文
医患纠纷英文作文英文：Medical disputes are a common occurrence in the healthcare industry, and they can be caused by a variety of factors. As a healthcare professional, I have encountered several medical disputes throughout my career. In my experience, the most common cause of medical disputes is miscommunication between healthcare providers and patients.In some cases, patients may not fully understand their medical condition, treatment options, or potential risks and side effects. This can lead to unrealistic expectations and misunderstandings, which can ultimately result in a medical dispute. As healthcare providers, it is our responsibility to ensure that patients are fully informed and understand their medical care.Another common cause of medical disputes is medical errors. Medical errors can occur due to a variety ofreasons, including misdiagnosis, incorrect medication dosages, and surgical errors. While healthcare providers strive to provide the best care possible, mistakes canstill happen. It is important for healthcare providers to acknowledge and address any mistakes that may have occurred and work to prevent them from happening in the future.In addition, cultural and language barriers can also contribute to medical disputes. Patients who do not speak the same language as their healthcare provider may have difficulty understanding their medical care, which can lead to misunderstandings and disputes. Healthcare providers should make an effort to provide interpretation services or find other ways to communicate effectively with patients who do not speak the same language.中文：医患纠纷在医疗行业中是很常见的，它们可以由各种因素引起。
实用医学英语写作
Abstract:Medical writing is an essential tool for disseminating research findings, clinical observations, and healthcare advancements. To ensure effective communication, it must adhere to high standards of quality and accuracy. This comprehensive guide delves into the multifaceted aspects of producing high-quality, standardized medical writing in English, addressing key elements such as structure, language, ethics, data presentation, referencing, and manuscript submission. It serves as a practical resource for researchers, clinicians, and students seeking to enhance their medical writing skills and meet international publishing standards.1. IntroductionMedical writing is a specialized form of scientific communication that bridges the gap between research and practice, fostering knowledge exchange among healthcare professionals worldwide. Given its profound implications on patient care and public health, it is crucial that medical writing meets stringent criteria of quality, clarity, and accuracy. This article provides a detailed analysis of the various dimensions that contribute to high-quality, standardized medical writing in English, with a focus on the following key aspects:a) Structure and organizationb) Language and stylec) Ethical considerationsd) Data presentation and interpretatione) Referencing and citationf) Manuscript preparation and submission2. Structure and OrganizationA well-structured medical paper enhances readability, facilitates comprehension, and ensures that information is presented logically and coherently. The standard structure of a biomedical research article typically includes:a) Title: Concise, informative, and indicative of the study's main findings or objectives.b) Abstract: A brief summary encapsulating the research question, methods, results, and conclusions.c) Introduction: Sets the context, outlines the research gap, and states the study aims.d) Methods: Detailed description of study design, participants, interventions, measurements, and statistical analyses.e) Results: Presentation of empirical data, supported by tables, figures, and statistical tests.f) Discussion: Interpretation of results, comparison with existing literature, limitations, and implications for future research or clinical practice.g) Conclusion: Succinct summary of the study's main findings and their significance.h) Acknowledgments: Recognition of funding sources, collaborators, and other contributions.i) Conflict of Interest Statement: Disclosure of any potential conflicts that may influence the research or its interpretation.j) References: List of cited sources formatted according to the target journal's guidelines (e.g., Vancouver, AMA, or APA styles).3. Language and StyleClear, concise, and precise language is vital in medical writing. Adhering to the following guidelines can significantly improve the quality of written communication:a) Use active voice wherever possible, as it often conveys information more directly and clearly than passive voice.b) Avoid jargon, complex sentences, and overly technical terms unless necessary; if used, provide clear definitions or explanations.c) Ensure consistency in terminology throughout the manuscript.d) Employ parallel structures for lists and comparisons to enhance clarity and readability.e) Proofread thoroughly for grammar, spelling, and punctuation errors, and consider using professional editing services if needed.4. Ethical ConsiderationsMedical writing must adhere to strict ethical principles to protect human subjects, maintain scientific integrity, and foster trust in the research community. Key ethical considerations include:a) Informed consent: All human subjects must provide voluntary, informed consent before participating in research, with appropriate documentation and approval from an institutional review board (IRB) or ethics committee.b) Confidentiality and data protection: Researchers must ensure the confidentiality and anonymity of study participants, especially when handling sensitive personal or health-related data.c) Authorship criteria: Adhere to established guidelines (e.g., ICMJE criteria) for assigning authorship, ensuring that all contributors who meet the criteria are included and that authorship order reflects their relative contributions.d) Declaration of interests: Transparently disclose any potential conflicts of interest that could influence the research, its conduct, or the interpretation of results.e) Animal welfare: If animal studies are involved, adherence to ethical guidelines and appropriate institutional approvals must be documented.5. Data Presentation and InterpretationAccurate and transparent data presentation is crucial for readers to evaluate the validity and reliability of research findings. Best practices include:a) Use appropriate statistical methods, and report them in detail to allow for replication.b) Present numerical data in tables and figures, ensuring they areself-explanatory, accurately labeled, and referenced in the text.c) Provide confidence intervals, p-values, and effect sizes where applicable, to convey the magnitude and certainty of observed effects.d) Avoid data manipulation or selective reporting; present all relevant findings, even those that do not support the study hypothesis.e) Interpret results cautiously, considering the study limitations, potential biases, and the broader context of existing literature.6. Referencing and CitationProper citation of sources is fundamental to academic integrity, acknowledges the work of others, and enables readers to trace the evidence underlying claims and arguments. Follow these guidelines:a) Use a recognized citation style consistently throughout the manuscript (e.g., Vancouver, AMA, or APA).b) Cite all sources of information, including direct quotes, paraphrased content, and data or ideas borrowed from other works.c) Verify the accuracy of references by cross-checking with the original source, and ensure complete and correct formatting according to the chosen citation style.d) Regularly update citations using reference management software to avoid outdated links or inaccessible resources.7. Manuscript Preparation and SubmissionThe final stage of high-quality medical writing involves preparing the manuscript for submission to a peer-reviewed journal. Key steps include:a) Target journal selection: Choose a journal that aligns with the study's scope, methodology, and impact, considering factors such as readership, acceptance rate, and open access options.b) Adherence to journal guidelines: Carefully follow the target journal's instructions for authors regarding manuscript structure, word count, formatting, and submission requirements.c) Cover letter: Write a compelling cover letter that highlights themanuscript's novelty, significance, and alignment with the journal's scope, and briefly addresses any potential reviewer concerns.d) Pre-submission checks: Conduct a thorough proofread, ensure all required files are included (e.g., manuscript, figures, tables, and supplementary materials), and verify compliance with the journal's formatting and style guidelines.e) Post-submission: Respond promptly and professionally to reviewer comments, addressing criticisms constructively and providing additional data or revisions as requested.Conclusion:Producing high-quality, standardized medical writing in English necessitates attention to multiple facets, including structure, language, ethics, data presentation, referencing, and manuscript submission. By adhering to these guidelines and best practices, researchers, clinicians, and students can enhance the clarity, accuracy, and impact of their written work, ultimately contributing to the advancement of medical knowledge and improved patient care. This comprehensive guide serves as a valuable resource for those seeking to refine their medical writing skills and meet the rigorous standards expected by the global scientific community.。
病历卡片英语作文格式
病历卡片英语作文格式Title: A Comprehensive Guide to Writing Medical Case Reports。
Introduction:Writing medical case reports in English is an essential skill for healthcare professionals worldwide. These reports serve as valuable tools for documenting patient cases, sharing clinical experiences, and contributing to medical literature. In this guide, we will outline the format and key components of a medical case report in English.Title:The title should succinctly summarize the key aspects of the case, including the patient's demographic information, primary diagnosis, and any unique or noteworthy features. For example, "A Rare Presentation of [Disease] in a [Age] [Gender]: A Case Report."Abstract:The abstract provides a concise overview of the case report, including the patient's presentation, diagnosis, and key findings. It should be structured to include the following sections:Background: Briefly describe the clinical context and relevance of the case.Case Presentation: Summarize the patient's demographic information, chief complaint, medical history, and relevant clinical findings.Diagnosis and Treatment: State the primary diagnosis and any additional diagnoses, as well as the treatment provided.Outcome: Describe the patient's clinical course and any relevant follow-up information.Introduction:The introduction sets the stage for the case report by providing background information on the disease orcondition being discussed. It should include a brief literature review to contextualize the case within the broader medical knowledge base. Additionally, it should clearly state the objective or purpose of the case report.Case Presentation:The case presentation provides a detailed descriptionof the patient's history, physical examination findings, laboratory results, imaging studies, and any otherpertinent clinical data. It should be organized chronologically and presented in a clear and logical manner. Each subsection should focus on a specific aspect of the case, such as the patient's presenting symptoms, diagnostic workup, or response to treatment.Diagnosis:In this section, the primary diagnosis and any relevant differential diagnoses should be discussed. The rationale for the diagnosis should be supported by the clinical findings and diagnostic tests outlined in the case presentation. Any challenges or uncertainties in reaching the diagnosis should also be addressed.Treatment:The treatment section outlines the interventions provided to the patient, including medications, procedures, and other therapeutic modalities. The rationale for each treatment should be explained, along with any relevant dosages, routes of administration, and monitoring parameters. Any adverse effects or complications related to the treatment should also be noted.Follow-up:The follow-up section provides information on the patient's clinical course after receiving treatment. This may include details on symptom resolution, diseaseprogression or regression, and any additional interventions or consultations. Long-term outcomes and prognosis should be discussed if applicable.Discussion:The discussion section offers a critical analysis of the case, highlighting its significance and relevance to clinical practice. This may involve comparing the case to similar cases reported in the literature, discussing potential mechanisms of disease, or reflecting on lessons learned from managing the patient. Strengths andlimitations of the case report should be acknowledged, and suggestions for future research or clinical practice may be offered.Conclusion:The conclusion summarizes the key points of the case report and emphasizes its clinical implications. It should reiterate the importance of the case in advancing medical knowledge and practice, and may also offer recommendationsfor further study or management strategies.References:All references cited in the case report should belisted in a separate reference section, following a standardized citation format such as AMA or APA. This allows readers to locate and review the sources cited in the text.Acknowledgments:Any individuals or organizations that contributed to the case report but do not meet the criteria for authorship should be acknowledged in this section. This may include colleagues who assisted with patient care or data collection, as well as funding sources or institutional support.Appendices:Any additional materials or supplementary informationthat is relevant to the case report but too detailed for inclusion in the main text can be included in appendices. This may include detailed laboratory results, imaging studies, or additional case data.In conclusion, writing a medical case report in English requires careful attention to detail and adherence to a standardized format. By following the guidelines outlined in this guide, healthcare professionals can effectively communicate their clinical experiences and contribute to the advancement of medical knowledge.。
临床医学 英文作文
临床医学英文作文英文：As a clinical medical practitioner, I am often faced with various challenges and complexities in my daily work. One of the biggest challenges is dealing with patients who have different personalities and backgrounds. Some patients are easy to communicate with, while others are moredifficult to handle. In such situations, I need to use my interpersonal skills to establish a good rapport with patients and gain their trust.For instance, I once had a patient who was very anxious and fearful about undergoing surgery. She had a lot of questions and concerns about the procedure, and I had to spend a lot of time explaining the details and addressing her fears. I had to be patient and empathetic, and reassure her that she was in good hands. By the end of our conversation, she felt more at ease and confident about the surgery.Another challenge I face is dealing with patients who have complex medical conditions that require a multidisciplinary approach. In such cases, I need to collaborate with other healthcare professionals, such as nurses, pharmacists, and therapists, to provide comprehensive care to the patient. This requires effective communication and coordination, as well as a willingness to learn from and respect the expertise of others.In addition, I also need to stay up-to-date with the latest medical research and technologies, and continuously improve my knowledge and skills. This requires a commitment to lifelong learning and professional development.中文：作为一名临床医学从业者，我每天都面临各种挑战和复杂情况。
医生误诊的案例作文英语
Misdiagnosis is a critical issue in the medical field, often leading to serious consequences for patients. It is a complex phenomenon that can arise from various factors, including human error, inadequate medical knowledge, or insufficient patient information. In this essay, I will recount a case of misdiagnosis that I encountered during my time as a medical professional, highlighting the importance of careful diagnosis and the potential ramifications of such errors.The case involved a middleaged man named John, who had been experiencing persistent headaches and fatigue for several weeks. He visited a local clinic where he was initially diagnosed with a common cold and prescribed medication to alleviate his symptoms. However, Johns condition did not improve, and the headaches became increasingly severe. Concerned, he sought a second opinion at a larger hospital.Upon further examination, the doctors at the hospital discovered that Johns symptoms were not indicative of a cold, but rather a more serious condition. Advanced imaging tests revealed a tumor in his brain, which had been overlooked in the initial diagnosis. The misdiagnosis had not only delayed Johns treatment but also put his life at risk.This case underscores the importance of thorough medical examinations and the need for healthcare professionals to stay updated with the latest medical knowledge. Misdiagnosis can occur when doctors rely too heavily on their initial impressions or fail to consider alternative explanations for a patients symptoms. In Johns case, the initial diagnosis was based on his symptoms alone, without the benefit of additional tests that could haveprovided a more accurate assessment of his condition.Moreover, the case highlights the potential consequences of misdiagnosis. Delayed treatment can exacerbate a patients condition, leading to more severe health complications or even death. In some instances, misdiagnosis can also result in unnecessary treatments or procedures, which can be physically and emotionally distressing for patients.To minimize the risk of misdiagnosis, healthcare professionals must adopt a comprehensive approach to patient care. This includes taking a detailed patient history, conducting thorough physical examinations, and utilizing appropriate diagnostic tests. Additionally, doctors should be open to considering alternative diagnoses and seeking second opinions when necessary.Furthermore, the medical community must continue to invest in education and training to ensure that healthcare professionals are equipped with the knowledge and skills needed to provide accurate diagnoses. This includes staying abreast of new medical research and advancements in diagnostic technology.In conclusion, the case of Johns misdiagnosis serves as a stark reminder of the potential dangers associated with inaccurate medical diagnoses. It emphasizes the need for healthcare professionals to approach patient care with diligence and caution, utilizing all available resources to ensure accurate diagnoses. By doing so, the medical community can help toprevent the serious consequences of misdiagnosis and provide patients with the best possible care.。
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describing the most significant or serious symptoms or signs of illness or dysfunction that caused him or her to seek health care.
Symptom State the major problem in brief patient’s words Followed by the duration Do not use medical terminology Be consistent with history of present illness 1-2 sentences, no more than 21 words
• Lower abdominal pain a week
History of present illness
It is an account obtained during the
interview with the patient of the onset, duration, and character of the present illness, as well as of any acts or factors that aggravate or ameliorate the symptoms.
The medical records are systematic
documentation of a patient’s medical history and care including the tests, lab, radiologic and pathologic information, etc.
Urinary system:
Lumbago / frequent micturition / urgent micturition / urodynia(尿痛) / dysuria(排尿困难) / hematuria / nocturia / polyuria / oliguria(少尿) / facial edema
Review of systems
Respiratory system:
Sore throat / chronic cough / sputum / hemoptysis（咯血） / wheezing （哮鸣） /dyspnea / chest pain
Cadiovascular system:
Biographical data
Name / Age / Sex / Marital status /
ห้องสมุดไป่ตู้
Nativity / Race / Occupation / Date of admission / Informant
Chief complaint
It is a subjective statement made by a patient
History of present illness
Onset：when, degree of urgency, prodrome,
induce factors of disease Features of the main symptom: location, character, duration, degree, severe or relieved factor Concomitant symptom Positive and negative symptom for differential diagnosis Treatment course General situation:
The medical records are divided into two
types. One is hospitalized medical records. Another is outpatient medical records.
Importance
A detailed medical record is very important
Chief complaint
• Chest pain • Queen Elizabeth is a 50yr old patient with chest pains for the last week. • Recurrent anterior chest pain more than a month after the event
prevent omission of significant data relative to the present illness is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the head toward the feet including respiratory system / cardiovascular system / digestive system / urinary system / hemopoietic system / endocrine system / nervous system / skeletal system.
Palpitation / dyspnea on exertion / hemoptysis / syncope / edema of lower limbs / precordial pain / hypertention
Review of systems
Digestive system:
Anorexia(厌食症) / sour regurgitation / belching(嗳气) / nausea / vomitting / abdominal distention / abdominal pain / constipation / diarrhea / hematemesis(呕血) / melena / hematochezia(便血) / jaundice
In writing up the history and the physical examination, the examiner should obey the following rules:
Record all pertinent (相关的) data, avoid
extraneous (无关的)data Use standard format Describe comprehensively, use common terms, avoid nonstandard abbreviations
Review of system
Hematopoietic system:
Fatigue / dizziness / blurred vision / gingival(牙龈) bleeding / subcutaneous hemorrhage / ostealgia(骨痛) / epistaxis(鼻衄)
It represents the only acceptable document in a court of law to record the events that transpired during the patient’s hospitalization.
The basic requirement of clinical records
The basic requirement of clinical records
Written in an all-round way, all items should be
filled, the hand writing should be clear, not scratchy or be altered Be objective, use diagram when indicated Be real, writing promptly Sign name clearly Check strictly, forbid smearing Law consciousness, respect the patient’s right
History of present illness
Past history
Review of all past illness, surgical
procedures, and injuries, and allergy history
Review of systems
a thorough evaluation and a double check
Case record
The case record should be written systemically and completely within 24 h by intern
Case record
Biographical data Chief complaint History of present illness Past history Personal history Marital history Menstrual history Childbearing (reproductive) history Family history Physical examination Laboratory tests and instrumental examination Primary diagnosis
for patient evaluation.
It guides the physician team’s decisions