医学英语病历报告书写

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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.。

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.。

英语病例报告作文

英语病例报告作文Title: Case Report in English。

Introduction:A case report is an important tool in medical research that documents the clinical presentation, diagnosis, and treatment of a patient. It is a detailed description of a patient's medical history, symptoms, physical examination, laboratory tests, and imaging studies. Case reports are often used to share rare or unusual cases, to describe new diseases or treatments, and to highlight diagnostic challenges or successes. In this article, we will discuss the key components of a case report and provide examples of how they are used in medical research.Case Presentation:The case presentation is the first section of a case report and provides an overview of the patient's medicalhistory, symptoms, and physical examination findings. It should include a brief summary of the patient's demographic information, medical history, and presenting symptoms. For example:A 45-year-old male with a history of hypertension and hyperlipidemia presented to the emergency department with chest pain and shortness of breath. He reported a sudden onset of severe chest pain that radiated to his left arm and jaw. He also complained of difficulty breathing and sweating profusely. On physical examination, he was found to have an elevated blood pressure and heart rate, and crackles were heard in his lungs.Diagnostic Studies:The second section of a case report is the diagnostic studies, which describe the laboratory tests, imaging studies, and other diagnostic procedures used to diagnose the patient's condition. It should include the results of any relevant laboratory tests, such as blood tests, urine tests, or imaging studies, such as X-rays, CT scans, orMRIs. For example:The patient's initial electrocardiogram (ECG) showedST-segment elevation in leads II, III, and aVF, consistent with an acute inferior myocardial infarction. A chest X-ray revealed bilateral pulmonary edema. Blood tests showed elevated troponin levels, indicating myocardial injury.Treatment and Outcome:The third section of a case report is the treatment and outcome, which describes the patient's response totreatment and their overall outcome. It should include a description of the treatment plan, any complications or adverse effects of treatment, and the patient's overall clinical course. For example:The patient was diagnosed with an acute inferior myocardial infarction and was treated with aspirin, heparin, and nitroglycerin. He underwent a cardiac catheterization, which revealed a 90% stenosis in the right coronary artery. The stenosis was successfully treated with percutaneouscoronary intervention (PCI) and a stent was placed. The patient's symptoms improved and he was discharged from the hospital on the third day after admission. He was prescribed antiplatelet and lipid-lowering medications and referred to cardiac rehabilitation.Discussion:The final section of a case report is the discussion, which provides an interpretation of the case and a review of the relevant literature. It should include a discussion of the diagnosis, treatment, and outcome of the case, as well as any relevant differential diagnoses, pathophysiology, or epidemiology. For example:Acute myocardial infarction is a common cause of chest pain and shortness of breath in middle-aged and elderly patients. The classic presentation of myocardial infarction is chest pain, which is often described as pressure or tightness and may radiate to the left arm, jaw, or back. The diagnosis of myocardial infarction is based on clinical presentation, electrocardiogram findings, and cardiacbiomarker levels. The treatment of myocardial infarction includes reperfusion therapy, which can be achieved with either PCI or thrombolytic therapy. The prognosis of myocardial infarction depends on the extent and severity of the myocardial damage and the presence of comorbidities.Conclusion:Case reports are an important tool in medical research that provide valuable insights into the diagnosis, treatment, and outcome of patients with rare or unusual conditions. They can also highlight diagnostic challenges or successes and contribute to the development of new treatments or diagnostic criteria. Writing a case report requires careful attention to detail and adherence to a standardized format. By following the key components of a case report, researchers can effectively communicate their findings and contribute to the advancement of medical knowledge.。

病例报告英语作文模板高中

病例报告英语作文模板高中Title: A Case Report: The Symptoms, Diagnosis, and Treatment of Influenza。

Introduction:Influenza, commonly known as the flu, is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness and even lead to hospitalization or death, especially in high-risk groups. Here, we present a case report of a patient with influenza, detailing their symptoms, diagnosis, and treatment.Patient History:The patient, a 35-year-old male, presented to theclinic with complaints of fever, cough, sore throat, body aches, fatigue, and headache. The symptoms had started suddenly two days prior to the visit and had progressively worsened. The patient denied any recent travel history orcontact with sick individuals but reported exposure to crowded areas due to work.Clinical Examination:On examination, the patient appeared ill and fatigued. Vital signs revealed a temperature of 39.2°C (102.5°F), heart rate of 100 beats per minute, respiratory rate of 22 breaths per minute, and blood pressure within normal limits. Examination of the respiratory system revealed bilateral coarse crackles on auscultation.Diagnostic Evaluation:Given the patient's clinical presentation during the influenza season, a presumptive diagnosis of influenza was made. Nasopharyngeal swab specimens were collected for laboratory confirmation. Rapid influenza diagnostic tests (RIDTs) were performed, which yielded positive results for influenza A virus. Additionally, reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the presence of influenza A virus subtype H3N2.Treatment:Based on the diagnosis of influenza A, the patient was initiated on antiviral therapy with oseltamivir (Tamiflu). The treatment regimen included oral oseltamivir 75 mg twice daily for a duration of five days. In addition, supportive measures were implemented to alleviate symptoms and prevent complications. These measures included adequate hydration, rest, and over-the-counter analgesics for fever and body aches.Clinical Course:Following initiation of antiviral therapy and supportive measures, the patient's symptoms gradually improved over the course of the next week. Fever subsided within 48 hours of starting oseltamivir, and respiratory symptoms began to resolve. The patient was advised to complete the full course of antiviral therapy and to follow up if symptoms persisted or worsened.Discussion:Influenza is a common viral illness characterized by respiratory symptoms and systemic manifestations. It is typically diagnosed based on clinical presentation and confirmed by laboratory testing. Early initiation of antiviral therapy, such as oseltamivir, can reduce the severity and duration of symptoms, especially if started within 48 hours of symptom onset. Supportive measures play a crucial role in managing influenza, particularly in alleviating symptoms and preventing complications.Conclusion:This case report highlights the clinical presentation, diagnosis, and management of influenza in a young adult male. Prompt recognition of symptoms, timely diagnosis, and initiation of appropriate treatment are essential in managing influenza and preventing its spread in the community. Healthcare providers should remain vigilant during influenza season and advocate for vaccination as themost effective preventive measure against influenza infection.。

病历书写英文

英文病历书写常用句式与表达
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英文病历书写注意事项
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Spelling mistakes
Typing errors or misspellings of words and names.
Grammar mistakes
Incorrect usage of verbs, nouns, adjectives, and pronouns, and incorrect sentence structure.
实例三：糖尿病病历
Symptoms：Itching, skin redness and scalingMedical history：None significantFamily history：None contributoryReview of systems：NegativePhysical examination：Multiple small red patches and scaling on the skin of the upper back and upper armsDiagnostic studies：Skin scrapings showed positive fungal elementsDiagnosis：DermatitisPlan：Patient was advised to apply topical corticosteroid cream twice daily and follow up in 1 week
实例二：高血压病历
Symptoms：Polyuria, polydipsia, unexplained weight lossMedical history：Known diabetes mellitus for 2 years, taking metformin hydrochlorideFamily history：None contributoryReview of systems：NegativePhysical examination：Blood pressure 130/85, pulse 90 beats/minute, respiration rate 18 breaths/minute, weight 150 poundsDiagnostic studies：Random blood glucose level of 250 mg/dL, HbA1c of 7.5%Diagnosis：Diabetes mellitusPlan：Patient was advised to continue current medications, receive education on diabetes self-management, lose weight, reduce glucose intake, and follow up in 3 months

医学英语病历报告书写

Case HistoryDefinitionA 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 theIt 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.)现病史(HPI or .)过去史(PMH or .)社会活动史/个人史(SHx or .)家族史(FHx or .)曾用药物(Meds)过敏史(All)To be continued系统回顾(ROS)体格检查(PE or .)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: . looks fair. Pharynx congested and tonsils enlarged. Chest and abdomen negative.Imp:Rp: Penicillin 400,000u. .) . x 3 days.Aspirin 1 tab. x 2 days.Vit C 100 mg x 3 daysSignature ______Chief Complaint .)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 .)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。

英文完全病历模板-详细版

Admission RecordName：* Nativity: * district, * citySex:male Race: HanAge:55 Date of admission:2020-09-07 14:30 Marital status: be married Date of record:2020-09-07 15:23 Occupation:teacher Complainer:patient himself Medical record Number: * Reliability: reliablePresent address: NO*, building*, * village,* district, *city, *provinceChief complaint: cough and sputum for more than 6 years, worsening for 2 weeksHistory of present illness: The patient complained of having paroxysmal cough and sputum 6 years ago. At that time, he was diagnosed as “COPD” in another hospital and no regular treatment was applied. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago with no inducing factors. Small amounts of white and mucous sputum were hard to cough up. Compared to daytime, tachypnea worsened in the night or when sputum can’t be cough up. The patient can’t lie flat at the night because of prominent tachypnea and prefer a high pillow. He had no fever, no chest pain, no dizziness, no diarrhea, no abdominal pain, no obvious decrease of activity tolerance. On 20*-0*-*, the patient went to *Hospital for medical consultation. CT lung imaging indicated: lesion accompanied by calcification in the superior segment, the inferior lobe of the right lung, the possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in the inferior lobe of the left lung; arteriosclerosis of coronary artery.Pulmonary function tests indicated:d obstructive ventilation dysfunction; bronchial dilation test was negative2.moderate decrease of diffusion function, lung volume, residual volume and the ratio of lungvolume; residual volume were normalThe patient was diagnosed as “AECOPD” and prescribed cefoxitin to anti-infection for a week, Budesonide and Formoterol to relieve bronchial muscular spasm and asthma,amb roxol to dilute sputum, and traditional Chinese medicine (specific doses were unknown).The patient was discharged from the hospital after symptoms of cough and sputum slightly relieved with a prescription of using Moxifloxacin outside the hospital for 1 week. Cough and sputum were still existing, thus the patient came to our hospital for further treatment and the outpatient department admitted him in the hospital with “COPD”. His mental status, appetite, sleep, voiding, and stool were normal. No obvious decrease or increase of weight.Past history: The patient was diagnosed as type 2 diabetes 1 years ago and take Saxagliptin (5mg po qd) without regularly monitoring the levels of blood sugar. The patient denies hepatitis, tuberculosis, malaria, hypertension, mental illness, and cardiovascular diseases. Denies surgical procedures, trauma, transfusion, food allergy and drug allergy. The history of preventive inoculation is not quite clear.Personal history: The patient was born in *district, * city and have lived in * since birth. He denies water contact in the schistosome epidemic area. Smoking 10 cigarettes a day for 20 years and have stopped for half a month. Denies excessive drinking and contact with toxics.Marital history: Married at age of 27 and have two daughters. Both the mate and daughters are healthy.Family history: Denies familial hereditary diseases.Physical ExaminationT: 36.5℃ P：77bpm R: 21 breaths/min BP：148/85mmHgGeneral condition：normally developed, well-nourished, normal facies, alert, active position, cooperation is goodSkin and mucosa: no jaundiceSuperficial lymph nodes: no enlargementHead organs: normal shape of headEyes:no edema of eyelids; no exophthalmos; eyeballs move freely; no bleeding spots of conjunctiva; no sclera jaundice; cornea clear; pupils round, symmetrical in size and acutely reactive to light.Ears: no deformity of auricle; no purulent secretion of the external canals; no tenderness over mastoidsNose: normal shape; good ventilation;no nasal ale flap; no tenderness over nasal sinus; Mouth: no cyanosis of lips; no bleeding spots of mouth mucosa; no tremor of tongue; glossy tongue in midline; no pharynx hyperemia; no enlarged tonsils seen and no suppurative excretions; Neck: supple without rigidity, symmetrical; no cervical venous distension; Hepatojugular reflux is negative; no vascular murmur; trachea in midline; no enlargement of thyroid glandChest: symmetrical; no deformity of thoraxLung:Inspection：equal breathing movement on two sidesPalpation: no difference of vocal fremitus over two sides;Percussion: resonance over both lungs;Auscultation: decreased breath sounds over both lungs; no dry or moist rales audible; no pleural friction rubsHeart:Inspection: no pericardial protuberance; Apex beat seen 0.5cm within left mid-clavicular at fifth intercostal space;Palpation: no thrill felt;Percussion: normal dullness of heart bordersAuscultation: heart rate 78bpm; rhythm regular; normal intensity of heart sounds; no murmurs or pericardial friction sound audiblePeripheral vascular sign: no water-hammer pulse; no pistol shot sound; no Duroziez’s murmur; no capillary pulsation sign; no visible pulsation of carotid arteryAbdomen:Inspection: no dilated veins; no abnormal intestinal and peristaltic waves seenPalpation: no tenderness or rebounding tenderness; abdominal wall flat and soft; liver and spleen not palpable; Murphy's sign is negativePercussion: no shifting dullness; no percussion tenderness over the liver and kidney regionAuscultation: normal bowel sounds.External genitalia: uncheckedSpine: normal spinal curvature without deformities; normal movementsExtremities: no clubbed fingers(toes); no redness and swelling of joints; no edema over both legs; no pigmentation of skins of legsNeurological system: normal muscle tone and myodynamia; normal abdominal and bicipital muscular reflex; normal patellar and heel-tap reflex; Babinski sign(-);Kerning sign(-) ; Brudzinski sign(-)Laboratory DataKey Laboratory results including CT imaging and pulmonary function test have been detailed in the part of history of present illness.Abstract*, male, 55 years old. Admitted to our hospital with the chief complaint of cough and sputum for more than 6 years, worsening for 2 weeks. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago. The patient can’t lie flat in the night because of prominent tachypnea and prefer a high pillow.Physical Examination: T: 36.5℃,P: 77bpm, R: 21 breaths per minute, BP:148/85mmHg. Decreased breath sounds over both lungs; no dry or moist rales audible.Laboratory data: CT lung imaging indicates: lesion accompanied by calcification in superior segment, inferior lobe of right lung, possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in inferior lobe of left lung. Pulmonary function tests indicate: mild obstructive ventilation dysfunction, bronchial dilation test was negative moderate decrease of diffusion function.Primary Diagnosis:1.AECOPD2.Type 2 Diabetes3.Primary Hypertension Doctor’s Signature:。

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.。

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•Present Illness .)简明病历书写手册.docThe course of onset•Date of onset•Mode of onset•Prodromal symptomsThe cardinal symptomsThe attack of illnessThe development of symptomsDiagnosis and treatmentGeneral conditionExampleSpecial language structures in presenting present illness1. 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 illness2. 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%的频率/的循环•持久/断断续续的Special language structures in presenting present illness3. 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 illness4. 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 illness5. 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 / intens ified / exacerbated by …•… remained the same as …, … continued, … persisted without changePast History .)简明病历书写手册.docHistory of vaccination and infectious diseasesHistory of allergy to drugs and other substancesHistory of surgical operation and external injurySystematic review of the past history and diseaseSpecial 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 history of … Except for … had no … / … no … apart from / but …Common diseases mentioned in past historymeasles, 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 .) /Social History简明病历书写手册.docLife style and habitOccupation and working environmentMarital & childbearing historyMenstrual historyTraveling historySpecial 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 beveragesSpecial 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… 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 confinementFamily History .)简明病历书写手册.docTerms 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 of patient’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)。