医学英语病历报告书写(简易版)
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.。
呼吸科英文病历范文
呼吸科英文病历范文ENGLISHCASE700756(Respiratory department)----------------------------Name: Liyuzhen `Age:42 yearsSex: FemaleRace: HanOccupation: Free occupationNationality: ChinaMarried status: married Addre: Qianjing Road No.16, Wuhan Hankou.thDate of admiion: July 26, 2001thDate of record: July 26, 2001Present illne:Two days ago the patient suddenly started to cough and feelHer spirit,sleep,appetite were normal.stool and urine werenormal, too.----------------------------PastHistory:General health status: normalOperation history: thyroidectomy.Infection history: No history of tuberculosis or hepatitis.Allergic history: allergic to a lot of drugs such as sulfanilamideTraumatic history: No traumatic history----------------------------SystemreviewRespiratorysystem: No history of repeated pharyngodynia, chroniccough, expectoration, hemoptysis, asthma, dyspneaor chest pain.Circulation system: No history of palpitation, hemoptysis, legsedema, short breath after sports, hypertension,precordium pain or faintne.Digestive system: No history of low appetite, sour regurgitation,belching, nausea, vomiting, abdominal distension,abdominal pain, constipation, diarrhea, hemaptysis,melena, hematochezia or jaundice.Urinary system: No history of lumbago, frequency of urination,urgency of urination, odynuria, dysuria, bloodyurine, polyuria or facial edemaHematopoietic system: No history of acratia, dizzine, gingivalbleeding, nasal bleeding, subcutaneous bleedingor ostealgia.Endocrine system: No history of appetite change, sweating, chillyexceive thirst, polyuria, hands tremor, character alternation, obesity, emaciation, hair change, pig- mentation or amenorrhea.Kinetic system: No history of wandering arthritis, joint pain, red swelling of joint, joint deformity, muscle painor myophagism.Neural system: No history of dizzine ,headache, vertigo, in- somnia, disturbance of consciousne, tremor, conv-ulsion, paralysis or abnormal sensation.--------------------------- Personal History:She was born in Hubei.She never smokes andDrinks.No exposurehistory to toxic substances,and infected water.Her menstruation was normal.LMP:23/7,2001----------------------------Family History:Her parents are living and well.No congenitaldisease in her family.---------------------------- PhysicalExaminationVital signs:T 36.6`C , P 80/min, R 22/min, BP120/80mmHg. General inspection: The patient is a well developed, well nou- rished adult female apparently in no acute distre,pleasant and cooperative.Skin:Normally free of eruption or unusual pigmentation. Lymphnodes: There are no swelling of lymphnodes. Head: Normal skull.No baldne, noscars.Eyes: No ptosis.Extraocular normal.Conjuctiva normal.The Pupils are round, regular, and react to light and ac-Ears: Externally normal.Canals clear.The drums normal.Nose: No abnormalities noted.Mouth and throat: lips red, tongue red.Alveolar ridges normal. Tonsils atrophil and uninfected.Neck: No adenopathy.Thyroid palpable,but not enlarged.No Abnormal pulsations.Trachea in middle.Chest and lung: Normal contour.Breast normal.Expansion equal. Fremitus normal.No unusual areas of dullne.Diaphr-agmatic position and excursion normal.No abnormal br-eath sound.No moist rales heard.No audible pleural fric-ion.There are lots of rhonchi rales and whoop can be heard thHeart: P.M.I 0.5cm to left of midolavicular line in 5 inter- Space.Forceful apex beat.No thrills.No pathologicheart murmur.Heart beat 80 and rhythm is normal. Abdomen: Flat abdomen.Good muscle tone.No distension.No v- isible peristalsis.No rigidity.No ma palpable.Tenderne (-), rebound tenderne (-).Liver and spleenare not palpable.Shifting dullne (-).Bowl soundsnormal.Systolic blowing murmur can be heard at theright side of the navel.Extremities: No joint disease.Muscle strength normal.No ab- normal motion.Thumb sign(+).Wrist sign(+).Neural system:Knee jerk (-).Achilles jerk (-).Babinski sign (-).Oppenheim sign (-).Chaddock sign (-).Conda sign (-).Hoffmann sign (-).Neck tetany (-)Kernig sign (-).Brudzinski sign (-).Genitourinary system: Normal.Rectum: No tenderne------Out-patient department data:No----------------------------Historysummary1).Li Yuzhen, female, 42y.2).Cough and dyspnea for 2 days3).PE: T 36.6`C, P 80/min, R 22/min, BP120/80mmHg.superficial nodes were not palpable.Normal vision.Upper palate haunch--uped.HR: 80bpm, rhythm is normal.There are lots of rho-nchi rales and whoop can be heard .Flat abdomen, Tenderne (-),rebound tenderne (-).Liver and spleen are not pal-pable.Shifting dullne (-).Bowl sounds normal..4).Outpatient data: see above.----------------------------Impreion: Bronchial asthmaSignature:He Lin 95-10033《英文病历.doc》。
病历汇报英文演讲稿范文
Good morning. Today, I am honored to present a case report on a patient who recently visited our medical facility. This case highlights a complex medical condition that required a multidisciplinary approach for diagnosis and treatment. I will discuss the patient's history, physical examination findings, laboratory and imaging results, and the subsequent management plan.Patient Information:- Name: John Smith- Age: 45 years- Gender: Male- Date of admission: March 15, 2023- Date of discharge: March 30, 2023Medical History:John Smith presented to our emergency department with a chief complaint of progressive shortness of breath and fatigue over the past two weeks. He reported a history of hypertension and type 2 diabetes mellitus,which were well-controlled on medication. He denied any recent illnesses, fever, cough, or weight loss.Physical Examination:On admission, Mr. Smith was found to have a blood pressure of 160/95 mmHg, heart rate of 110 bpm, respiratory rate of 22 breaths per minute, and tempera ture of 37.2°C. His general appearance was anxious, and he had significant edema in both lower extremities. Cardiovascular examination revealed a grade II/VI systolic ejection murmur at the left sternal border, and pulmonary examination was notable for bilateral wheezing and rales.Laboratory and Imaging Results:- Complete blood count (CBC): Mild anemia with hemoglobin of 10.2 g/dL, white blood cell count of 12,000/µL, and platelet count of 150,000/µL.- Electrolytes, renal function tests, and liver function tests were within normal limits.- Serologic tests for HIV, hepatitis B, and hepatitis C were negative.- Chest X-ray: Bilateral pulmonary edema and cardiomegaly.- Echocardiogram: Severe left ventricular dysfunction with an ejection fraction of 25%.- CT scan of the chest: Pulmonary embolism involving the left main pulmonary artery.Diagnosis:Based on the clinical presentation, laboratory findings, and imaging results, the patient was diagnosed with acute pulmonary embolism (PE) with secondary pulmonary hypertension and left ventricular dysfunction.Management Plan:- Anticoagulation therapy with heparin and apixaban was initiated to prevent further thromboembolic events.- Mechanical ventilation was required due to severe respiratory distress.- Inotropic support was provided to manage hypotension and improve cardiac output.- Treatment for secondary pulmonary hypertension included diuretics, nitrates, and inhaled bronchodilators.- Antibiotics were prescribed for a suspected lower respiratory tract infection.- The patient was also started on a low-sodium diet and received education on fluid management.Outcome:After a week of intensive care, Mr. Smith's clinical status improved significantly. His respiratory distress resolved, and he was able to beweaned off mechanical ventilation. His blood pressure stabilized, and the inotropic support was discontinued. By the time of discharge, his ejection fraction had improved to 30%, and he was discharged on apixaban and hydrochlorothiazide to manage his hypertension and diabetes.Conclusion:This case report illustrates the importance of early diagnosis and treatment of pulmonary embolism, which can be a life-threatening condition. The multidisciplinary approach, including emergency medicine, cardiology, pulmonology, and critical care, was crucial in managing this complex case. Mr. Smith's recovery demonstrates the potential for successful outcomes with appropriate medical intervention.Thank you for your attention, and I would be happy to answer any questions you may have.。
英语病历作文格式模板
英语病历作文格式模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。
A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。
A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。
A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。
病例报告英文范文医护英语
病例报告英文范文医护英语Title: Case Report: Management of a Complex Surgical Case with Multi-system Involvement.Introduction:Surgical cases with multi-system involvement present unique challenges to the treating healthcare team. This case report outlines the management of a complex surgical case with involvement of multiple organ systems, highlighting the importance of interdisciplinary collaboration and comprehensive preoperative planning.Case Presentation:The patient, a 56-year-old male with a history of hypertension and type 2 diabetes, presented to the emergency department with complaints of severe abdominal pain and distension. Initial evaluation revealed a large abdominal mass with ascites. Computed tomography (CT) scanconfirmed the presence of a large, complex abdominal mass with extension into the retroperitoneum, compressing the adjacent organs and vessels.Diagnostic Workup:The patient underwent a series of diagnostic tests including blood work, imaging studies, and consultations with various specialists. The laboratory tests revealed anemia and elevated liver enzymes. The imaging studies, including CT scan and magnetic resonance imaging (MRI), demonstrated a large mass with heterogeneous enhancement, compressing the adjacent organs and vessels. The mass was suspected to be a malignant neoplasm, possibly originating from the pancreas or adrenal glands.Preoperative Planning:Given the complexity of the case and the involvement of multiple organ systems, a preoperative planning meeting was held with the surgeons, anesthesiologists, intensivists, radiologists, pathologists, and oncology team. The plan wasto perform a laparotomy with excision of the mass, followed by reconstruction of the affected organs and vessels. The anesthesiologists recommended a general anesthetic with invasive monitoring, while the intensivists recommended postoperative admission to the intensive care unit (ICU)for close monitoring.Surgical Procedure:The laparotomy was performed through a midline incision. Intraoperatively, the mass was found to be adherent to multiple organs and vessels, including the liver, spleen, kidney, and inferior vena cava. Careful dissection was performed to separate the mass from the adjacent structures, while preserving the vascular integrity. The mass was successfully excised, and the affected organs were reconstructed using sutures and patches. The patient tolerated the procedure well, and hemostasis was achieved.Postoperative Course:The patient was admitted to the ICU for closemonitoring. Postoperatively, he developed transient respiratory failure and required mechanical ventilation. He also developed wound dehiscence due to the extensive surgical dissection. The ICU team managed the patient's respiratory status and provided wound care. The patient gradually improved and was extubated on the third postoperative day. He was transferred to the general surgical floor on the fifth postoperative day and discharged home on the tenth postoperative day.Pathological Analysis:The pathological examination of the excised mass revealed a poorly differentiated adenocarcinoma, likely originating from the pancreas. The surgical margins were negative for tumor involvement. The patient was referred to the oncology team for further management, including adjuvant chemotherapy and follow-up surveillance.Conclusion:This case report demonstrates the successful managementof a complex surgical case with multi-system involvement. The interdisciplinary collaboration and comprehensive preoperative planning were essential for achieving a successful outcome. The case highlights the importance of a multidisciplinary approach in the management of complex surgical cases, ensuring optimal patient care.。
英文病历报告作文模板
英文病历报告作文模板Patient Information- Name: [Patient's Full Name]- Gender: [Male/Female]- Age: [Patient's age]- Date of Admission: [MM/DD/YYYY]Chief ComplaintThe patient presented with [specific symptoms/complaints] which started [duration].History of Present IllnessThe patient reported [detailed description ofsymptoms/complaints]. The symptoms worsened over the past [duration]. The patient experienced [associated symptoms] and tried [any self-medication or home remedies] but noticed no improvement. There was no history of trauma or injury.Past Medical HistoryThe patient has a history of [chronic/acute medical conditions, if any] which includes [specific conditions]. The patient has taken[previous medications/treatments] for these conditions.Social HistoryThe patient has a [specific occupation] and lives in [specific area]. The patient does [specific habits] such as smoking or drinking alcohol [frequency]. There is no significant family medical history.Physical Examination- Vital Signs:- Blood Pressure: [value] mmHg- Heart Rate: [value] bpm- Respiratory Rate: [value] bpm- Temperature: [value]C- General Appearance:The patient appears [general appearance of the patient].- Systemic Examination:- Cardiovascular: [specific findings]- Respiratory: [specific findings]- Gastrointestinal: [specific findings]- Neurological: [specific findings]- Musculoskeletal: [specific findings]Laboratory and Imaging Findings- Blood Test Results:- Complete Blood Count: [values]- Biochemical Profile: [values]- Others: [specific findings]- Imaging:- [Specific imaging tests performed]- Results: [specific findings]DiagnosisAfter evaluating the patient's medical history, physical examination, and laboratory/imaging findings, the following diagnosis was made:[Primary Diagnosis]Treatment and ManagementThe patient was started on [specific treatment plan] which includes [medications, therapies, or procedures]. The patient wasadvised to [specific instructions] and scheduled for [follow-up tests/appointments, if any].Follow-upThe patient will be followed up in [specific time frame] to assess the response to treatment and manage any complications that may arise. The patient was given contact information for any urgent concerns or changes in symptoms.Discussion and ConclusionThis case report highlights the presentation, evaluation, and management of a patient with [specific condition]. The patient's symptoms were appropriately addressed through a systematic approach involving history taking, physical examination, and laboratory/imaging investigations. The provided treatment plan aims to address the underlying cause and improve the patient's overall well-being. Continuous monitoring and follow-up will guide further management decisions.Note: This medical case report is fictional and serves as a template for educational purposes. Any resemblance to actualpatients is purely coincidental.。
写一篇填写病人信息的报告单英语作文
写一篇填写病人信息的报告单英语作文全文共3篇示例，供读者参考篇1Medical ReportPatient Information:Name: Jane SmithDate of Birth: February 15, 1985Sex: FemaleOccupation: AccountantAddress: 123 Main Street, Anytown, USAPhone Number: 555-555-5555Medical History:- Jane has a history of hypertension, which has been well-controlled with medication.- She has a family history of heart disease, with her father having suffered a heart attack at the age of 60.- Jane does not smoke and does not consume alcohol in excess.- She exercises regularly, with a mix of cardio and strength training.- She does not have any known allergies to medications.Presenting Complaint:Jane presented to the clinic with complaints of chest pain and shortness of breath over the past week. She describes the chest pain as a dull ache that is present at rest and with exertion. She also reports feeling lightheaded and fatigued.Physical Examination:- Vital signs: Blood pressure 140/90 mmHg, heart rate 80 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F.- Cardiovascular: Regular rate and rhythm, no murmurs or gallops.- Respiratory: Clear to auscultation bilaterally.- Abdomen: Soft and non-tender, no hepatomegaly or splenomegaly.- Neurological: Cranial nerves intact, no focal deficits.Assessment and Plan:Based on Jane's symptoms and history, the working diagnosis is angina pectoris. Further workup will include an EKG, stress test, and lipid profile. We will also consider a cardiology consultation for further evaluation and management.Medications:- Lisinopril 10 mg daily for hypertension- Aspirin 81 mg daily for cardiovascular protectionFollow-up:Jane will be scheduled for a follow-up appointment in one week to review the results of her tests and adjust her treatment plan accordingly. She is advised to monitor her symptoms closely and seek immediate medical attention if they worsen or if she experiences chest pain at rest. She is also encouraged to continue her regular exercise routine and maintain aheart-healthy diet.Doctor's Signature:Dr. John DoeDate: January 15, 2023This report is based on the information provided by the patient and the findings of the physical examination. Any further recommendations will be communicated after the completion of additional tests.篇2Patient Information ReportName: John SmithAge: 45Gender: MaleDate of Birth: January 15, 1976Address: 123 Main Street, Anytown, USAPhone Number: 555-123-4567Occupation: AccountantEmergency Contact: Jane Smith (wife) - 555-987-6543Medical History:- Hypertension: Diagnosed in 2010, currently managing with medication- Type 2 Diabetes: Diagnosed in 2015, managing with diet and exercise- Hyperlipidemia: Diagnosed in 2017, managing with medication- Allergies: None reported- Surgeries: Appendectomy in 2001- Hospitalizations: None reportedCurrent Medications:- Lisinopril 10mg daily for hypertension- Metformin 1000mg twice daily for diabetes- Atorvastatin 20mg daily for hyperlipidemiaVitals:- Blood Pressure: 130/80 mmHg- Heart Rate: 70 bpm- Temperature: 98.6°F- Respiratory Rate: 16 breaths per minute- Weight: 180 lbs- Height: 5'10"Assessment:- Patient presents with well-controlled hypertension, diabetes, and hyperlipidemia.- No signs of acute distress.- Patient is alert and oriented, with appropriate answers to questions.Plan:- Continue current medications as prescribed.- Schedule follow-up appointment in 3 months for routine blood work and monitoring.Doctor's Signature: Dr. Emily JohnsonDate: October 20, 2021This patient information report is confidential and intended for medical use only. Please keep this information secure and only share with authorized healthcare providers. Thank you.篇3Patient Information Report FormPatient Name: John SmithDate of Birth: January 10, 1975Gender: MaleOccupation: Software EngineerAddress: 123 Main Street, Cityville, StatePhone Number: (555) 123-4567Emergency Contact: Jane Smith (Spouse)Emergency Contact Phone Number: (555) 987-6543Chief Complaint: Mr. Smith presents with complaints of persistent headache and dizziness for the past two weeks. He also reports occasional nausea and blurry vision.Medical History:- Hypertension: Diagnosed 5 years ago, currently taking antihypertensive medication as prescribed by his primary care physician.- Hyperlipidemia: Diagnosed 3 years ago, currently taking statin medication to manage cholesterol levels.- Type 2 Diabetes: Diagnosed 2 years ago, managed with diet and exercise, no medication required.- Allergies: No known allergies to medications or food.- Surgical History: Appendectomy at age 20, no other significant surgeries.Family History:- Hypertension: Father and paternal grandmother- Heart Disease: Mother and maternal grandfather- Diabetes: Maternal grandmotherSocial History: Mr. Smith is a non-smoker and rarely consumes alcohol. He exercises regularly by going for a jog three times a week and follows a healthy diet rich in fruits and vegetables. He is happily married with two children and feels supported at home.Review of Systems:- General: Fatigue, weight loss- Cardiovascular: No chest pain, palpitations- Respiratory: No shortness of breath, cough- Gastrointestinal: Occasional indigestion, no changes in bowel habits- Neurological: Headache, dizziness, blurry vision, no weakness or numbness- Musculoskeletal: No joint pain or stiffness- Dermatological: No rash or skin changesPhysical Examination:- Vital Signs: Blood pressure 140/90 mmHg, heart rate 80 bpm, temperature 98.6°F, respiratory rate 16 breaths/min- General: Well-appearing middle-aged male in no acute distress- Head and Neck: No signs of trauma, pupils equal and reactive to light- Cardiovascular: Regular rate and rhythm, no murmurs or rubs- Respiratory: Clear breath sounds bilaterally- Abdomen: Soft, non-tender, no organomegaly- Neurological: Cranial nerves intact, no focal deficitsAssessment and Plan:1. Hypertension: Increase dosage of antihypertensive medication and monitor blood pressure at home regularly. Follow up with primary care physician in two weeks forre-evaluation.2. Headache and Dizziness: Order MRI of the brain to rule out intracranial pathology. Provide symptomatic relief with analgesics as needed.3. Hyperlipidemia: Continue current statin therapy and counsel on dietary modifications to improve cholesterol levels.4. Type 2 Diabetes: Monitor blood glucose levels at home and follow up with primary care physician for hemoglobin A1c testing in three months.Follow-up:Mr. Smith to follow up with primary care physician for review of MRI results and adjustment of management plan in two weeks. In the meantime, he is advised to rest, stay hydrated, and avoid driving or operating heavy machinery due to dizziness.Signature: Dr. Emily JohnsonDate: May 25, 2022This report form captures the essential information about Mr. Smith's medical history, current complaints, physical examination findings, and a comprehensive assessment and plan for his management. It will serve as a guide for his primary care physician to further investigate and address his health concerns.。
英语病历报告作文格式
英语病历报告作文格式英文回答：Medical Report Format.The medical report format varies depending on the purpose and intended audience of the report. However, there are some general guidelines that can be followed whenwriting a medical report.The report should be organized into the following sections:Introduction: This section should provide a brief overview of the patient's condition, including the reasonfor the report.Medical History: This section should include adetailed account of the patient's medical history,including any previous illnesses, surgeries, or medications.Physical Examination: This section should describe the patient's physical examination findings, including vital signs, general appearance, and any abnormalities.Laboratory and Imaging Studies: This section should summarize the results of any laboratory tests or imaging studies that have been performed.Diagnosis: This section should provide a diagnosis of the patient's condition, based on the information gathered in the previous sections.Treatment Plan: This section should outline the treatment plan that has been recommended for the patient.Prognosis: This section should provide an estimate of the patient's prognosis, including the expected course of treatment and the likelihood of recovery.The report should be written in clear and concise language, using medical terminology where appropriate. Itshould also be organized in a logical way, with eachsection building on the previous one.中文回答：病历报告格式。
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⏹Case History⏹DefinitionA case history is a medical record of a patient’s illness. It records the whole medical case and functions as the basis for medical practitioners to make an accurate diagnosis and proposes effective treatment or preventive measures.Case histories fall into two kinds:in-patient case histories and out-patient case histories.⏹Language FeaturesHistory and Physical usually involves past tense ( for history of present illness, past medical history, family history and review of systems concerning past information), and present tense ( review of system, physical examination, laboratory data, and plans ).Structurally, noun phrases are frequently used in physical examination, and ellipsis of subject is very common in review of system.⏹In-patient Case HistoriesAn in-patient case history is also termed as History and Physical. It is an account of a patient’s present complaints with descriptions of his past medical history,and the description of the present conditions as well as physical examinations and impression about the conditions.FormatIt usually consists of chief complaint, history of present illness, past medical history, review of systems, physical examination, impression, family history, social history, medications, allergies, laboratory on admission, and plan. However, what parts are included depends on the needs.住院病人病历完整模式病历（Case History）姓名(Name) 职业(Occupation)性别(Sex) 住址(Address)年龄(Age or DOB) 供史者(Supplier of history)婚姻(Marital status) 入院日期(Date of admission)籍贯(Place of birth) 记录日期(Date of record)民族(Race)主述(C.C.)现病史(HPI or P.I.)过去史(PMH or P.H.)社会活动史/个人史(SHx or Per.H.)家族史(FHx or F.H.)曾用药物(Meds)过敏史(All)To be continued系统回顾(ROS)体格检查(PE or P.E.)体温(T) 呼吸(R)血压(BP) 脉搏(P)一般状况(General status)皮肤黏膜(Skin & mucosa)头眼耳鼻喉(HEENT)颈部(Neck)胸部与心肺(Chest, Heart and Lungs)腹部(Abdomen)肛门直肠(Anus & rectum)外生殖器(External genitalia)四肢脊柱(Extremities & spine)神经反射(Nerve reflex)To be continued化验室资料(Lab data)(Blood test, Chem-7, EKG, EEG, X-ray examinations or X-ray slides, CT and NMR…)印象与诊断(Impression and diagnosis, or Imp)住院治疗情况记录(Hospital course)出院医嘱(Discharge instructions or recommendations)出院后用药(Discharge medications)医师签名(Signature)⏹Patterns and contents of an out-patient case historyContents: general data (GD), chief complaint (CC), present illness (PI), physical examination (PE), tentative diagnosis (TD) or impression (Imp), treatment (Rp), etc.An out-patient case history should be written in brief and to the very point. More abbreviations and noun phrases are used.⏹Sample of an out-patient case historyMale, 39 year oldCC: Fever, headache and cough for two days.PE: G.C. looks fair. Pharynx congested and tonsils enlarged. Chest and abdomen negative.Imp: U.R.I.Rp: Penicillin 400,000u. (i.m.) q.d. x 3 days.Aspirin 1 tab. t.i.d. x 2 days.Vit C 100 mg t.i.d. x 3 daysSignature ______⏹Chief Complaint (C.C.)⏹ 1. Sentence patterns in chief complaint•症状+for+时间•症状+of+时间+duration•症状+时间+in duration•时间+of+症状•症状+since+时间⏹Chief Complaint (C.C.)⏹ 2. Commonly-used complaints:•weakness, malaise, chills, fever, pain, headache, nausea and vomiting, diarrhea, neuro-psychiatric disorders, shortness of breath, bleeding or discharge, insomnia,stomachache, dyspepsia, no appetite, dysuria, cough, difficulty in coughing up sputum, sorethroat, dizziness, palpitation, restlessness, etc. •弱点,不适感,发冷、发烧、疼痛、头痛、恶心、呕吐、腹泻、neuro-psychiatric紊乱、气短、出血或排放、失眠、胃痛,消化不良,没有胃口,排尿困难、咳嗽、咳痰、困难、喉咙痛、头晕、心悸、不安等。
•Present Illness (P.I.)简明病历书写手册.doc(p.27-35)⏹The course of onset•Date of onset•Mode of onset•Prodromal symptoms⏹The cardinal symptoms⏹The attack of illness⏹The development of symptoms⏹Diagnosis and treatment⏹General condition⏹Example⏹Special language structures in presenting present illness⏹ 1. Describing the course of onset•… started / began having / feeling …•… first noticed / noted / perceived / recognized the onset of …•… are the prodrome of …, … herald …⏹Special language structures in presenting present illness⏹ 2. Describing the mode and regularity of onset•explosively / suddenly / acutely / abruptly•gradually / chronically / increasingly / insidiously•occasionally / accidentally•often / frequently / in frequency / recurrently•persistently / intermittently⏹爆炸性/突然/强烈•/突然⏹长期/越来越多•逐渐/ /在不知不觉之中⏹•偶尔/偶⏹经常/经常在0.9%的频率/的循环⏹•持久/断断续续的⏹Special language structures in presenting present illness⏹ 3. Describing the cardinal symptoms•… had / presented / developed / showed / manifested …•… characterized by …•… admits to …•… states that …•… feels …•… denies …, … without / free of symptoms…⏹Special language structures in presenting present illness⏹ 4. Describing the attack of illness•… appeared / occurred / came on …•… had / developed episodes / attacks of …•… was associated with …, …was accompanied by …, … was followed by …, … had relation to …•… was preceded / heralded by …⏹Special language structures in presenting present illness⏹ 5. Describing the development of symptoms•… disappeared / ceased / subsided …•… took a favorable turn …., …took a turn for the better …, …relieved / improved / alleviated …•… took a bad / unfavorable turn …, … took a turn for the worse …, …was aggravated / intensified / exacerbated by …•… remained the same as …, … continued, … persisted without change⏹Past History (P.H.)简明病历书写手册.doc(p.36)⏹History of vaccination and infectious diseases⏹History of allergy to drugs and other substances⏹History of surgical operation and external injury⏹Systematic review of the past history and disease⏹Special language structures in presenting past history⏹… had enjoyed good health until… / … had been sound / well / healthy until…⏹… had never been ill before … / had no illness of any kind before …⏹… denied any history of / had no related history of / … denied experiencing / having attack of …⏹No history of … / No history suggestive of / indicative of …⏹… suffered from … / … had an attack of … / … was attacked / troubled by / … had a past historyof …⏹Except for … had no … / … no … apart from / but …⏹Common diseases mentioned in past history⏹measles, mumps, chicken-pox, smallpox, pertussis, influenza, scarlet fever, diphtheria, typhoid fever,bronchitis, pneumonia, encephalitis, meningitis, tetanus, poliomyelitis, dysentery, cholera, pleurisy, tonsillitis, rheumatism, malaria, tuberculosis, jaundice, allergy, sexually transmitted diseases, gonorrhea, syphilis, sequela, complication, hospitalization…⏹麻疹,腮腺炎,chicken-pox氮、天花、百日咳、流行性感冒、猩红热、白喉、伤寒、支气管炎、肺炎、脑炎、脑膜炎、破伤风、脊髓灰质炎(小儿麻痹)、痢疾、霍乱、胸膜炎、扁桃体炎、风湿、疟疾、肺结核、黄疸、过敏、性传播疾病、淋病、梅毒、后遗症、并发症、住院…⏹Personal History (Per.H.) /Social History简明病历书写手册.doc(p.37)⏹Life style and habit⏹Occupation and working environment⏹Marital & childbearing history⏹Menstrual history⏹Traveling history⏹Special language structures in presenting personal habits⏹…have a long history of smoking / drinking⏹…have a lifelong like / dislike for…⏹…admitted to excessive use of…⏹…denies the use of alcoholic beverages⏹Special language structures in presenting occupational history⏹…work / act / serve as…⏹…be engaged in…⏹…practice one’s profession in …⏹…be exposed to industrial poisons / dust / radioactive substances / hazards / toxic substances…⏹Special language structures in presenting marital & childbearing history简明病历书写手册.doc(p.38-39)⏹… have been married for … years without conception⏹… have a history of abortion or premature births⏹… delivered one normal / abnormal infant⏹… delivered … days before / prior to the expected date of confinement⏹Family History (F.H.)简明病历书写手册.doc(p.39)⏹Terms mentioned in family history•family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia,syphilis, tumor, epilepsy, allergy, etc. any contact with diseased individuals, relationship ofpatient’s childhood and adult life; age, health condition, and cause of death of parents,grandparents, self, spouse, siblings or relatives. 家庭的倾向,存在•遗传疾病、癌症、肺结核、精神障碍和紧张的感情、风湿、糖尿病、高血压、脑血管意外、血友病、梅毒、肿瘤、癫痫、过敏等任何接触患病的个人关系,病人的童年和成年生活;年龄、健康状况、和死亡原因的父母、祖父母、本人,配偶、兄弟姐妹或不相关的亲戚(联系)。