英文病例汇报模板
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.。
英语病历报告作文格式
英语病历报告作文格式English:A medical record report in English typically follows a specific format to ensure clear and organized documentation of a patient's medical history, diagnosis, treatment, and progress. The report usually starts with the patient's demographic information, including their name, age, gender, address, and contact information. This is followed by the reason for the patient's visit or hospitalization, including the chief complaint and any relevant medical history. The report then details the physical examination findings, laboratory and imaging test results, diagnosis, treatment plan, and prognosis. It is important to use clear and concise language, medical terminology, and abbreviations to accurately convey the patient's medical information. Additionally, proper grammar, spelling, and punctuation should be used to ensure professionalism and accuracy in the medical record report.中文翻译:英文病历报告通常遵循特定的格式，以确保清晰有序地记录患者的病史、诊断、治疗和进展情况。
英语病例报告范文
英语病例报告范文Case Report: A Rare Case of Acute Myeloid Leukemia with Unusual Presentation。
Introduction:Acute Myeloid Leukemia (AML) is a malignant disorder characterized by the proliferation of abnormal myeloid cells in the bone marrow. It typically presents with symptoms such as fatigue, fever, and easy bruising. However, in some rare cases, AML can manifest with atypical symptoms, leading to diagnostic challenges. This report presents a unique case of AML with an unusual presentation.Case Presentation:A 45-year-old male presented to the emergency department with complaints of severe headaches, dizziness, and blurred vision. He had a history of chronic migraines and was initially treated for a severe migraine attack. However, his symptoms did not improve with standard migraine medications. On further evaluation, the patient was found to have profound anemia, with a hemoglobin level of 6 g/dL.Investigations:A complete blood count revealed severe pancytopenia, with a white blood cell count of 1.2 × 10^9/L, hemoglobin of 6 g/dL, and platelet count of 50 × 10^9/L. Peripheral blood smear examination showed blasts comprising 70% of the total nucleated cells, suggesting the possibility of acute leukemia. Bone marrow aspiration and biopsy were performed to confirm the diagnosis.Diagnosis:The bone marrow examination revealed hypercellularity with infiltration of blasts comprising more than 80% of the nucleated cells. Flow cytometry analysis showed expression of myeloid markers (CD13, CD33) and absence of lymphoid markers,confirming the diagnosis of acute myeloid leukemia. Cytogenetic analysis revealed the presence of a complex karyotype, which is associated with a poor prognosis.Treatment and Outcome:The patient was promptly started on induction chemotherapy with a combination of cytarabine and daunorubicin. He experienced severe myelosuppression and required supportive care, including red blood cell and platelet transfusions. Despite the initial response to chemotherapy, the patient developed refractory disease and relapsed within six months of completing consolidation therapy. Salvage chemotherapy and allogeneic stem cell transplantation were considered, but the patient declined further treatment due to poor prognosis and opted for palliative care.Discussion:This case highlights the importance of considering acute leukemia in the differential diagnosis of atypical presentations, even in the absence of classic symptoms. The unusual symptoms of severe headaches, dizziness, and blurred vision initially misled the clinicians to suspect migraine as the primary cause. However, the presence of profound anemia and pancytopenia raised suspicion of an underlying hematological disorder. Timely evaluation and appropriate diagnostic tests, including bone marrow examination, were crucial in establishing the correct diagnosis.Conclusion:This case report emphasizes the need for a high index of suspicion for acute leukemia, especially in patients presenting with unusual symptoms. Prompt diagnosis and initiation of appropriate treatment are essential for improving patient outcomes. Further research is warranted to better understand the underlying mechanisms of atypical presentations in AML and to develop targeted therapies for patients with poor prognostic factors.。
最新英文住院病例模板
Divisi on: _________ Ward: __________ Bed: _________ Case No. ___________Name: _____________ Sex: __________ Age: ___________ Natio n: ___________ Birth Place: ________________________________ Marital Status: _____________ Work-orga nizatio n & Occupatio n: _____________________________________ Livi ng Address & Tel: _________________________________________________ Date of admissio n: ______ D ate of history taken: ______ Informant: __________Chief Complaint: ___________________________________________History of Present Illness:Past History:General Health Status: 1.good 2.moderate 3.poorDisease history:(if any, please write down the date of onset, brief diagnosticand therapeutic course, and the results.)Respiratory system:1. None2.Repeated pharyngeal pain3.chronic cough4.expectoration:5. Hemoptysis6.asthma7.dyspnea8.chest painCirculatory system:1.None2.Palpitation3.exertional dyspnea4..cyanosis5.hemoptysis6.Edema of lower extremities7.chest pain8.syncope9.hypertension Digestive system:1.None2.Anorexia3.dysphagia4.sour regurgitation5.eructation6.nausea7.Emesis8.melena9.abdominal pain 10.diarrhea11.hematemesis 12.Hematochezia 13.jaundiceUrinary system:1.None2.Lumbar pain3.urinary frequency4.urinary urgency5.dysuria6.oliguria7.polyuria 8.retention of urine 9.incontinence of urine 10.hematuria11.Pyuria 12.nocturia 13.puffy faceHematopoietic system:1.None2.Fatigue3.dizziness4.gingival hemorrhage5.epistaxis6.subcutaneous hemorrhageMetabolic and endocrine system:1.None2.Bulimia3.anorexia4.hot intolerance5.cold intolerance6.hyperhidrosis7.Polydipsia8.amenorrhea9.tremor of hands 10.character change 11.Marked obesity12.marked emaciation 13.hirsutism 14.alopecia15.Hyperpigmentation 16.sexual function changeNeurological system:1.None2.Dizziness3.headache4.paresthesia5.hypomnesis6. Visual disturbance7.Insomnia8.somnolence9.syncope 10.convulsion 11.Disturbance of consciousness12.paralysis 13. vertigoReproductive system:1.None2.othersMusculoskeletal system:1.None2.Migrating arthralgia3.arthralgia4.artrcocele5.arthremia6.Dysarthrosis7.myalgia8.muscular atrophyInfectious Disease:1.None2.Typhoid fever3.Dysentery4.Malaria 4.Schistosomiasis4. Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever9.othersVaccine inoculation:1.None2.Yes3.Not clearVaccine detail _________________________________________ Trauma and/or operation history: Operations:1.None2.YesOperation details: _______________________________________ Traumas:1.None2.YesTrauma details: _________________________________________ Blood transfusion history:1.None2.Yes ( 1.Whole blood 2.Plasma3.Ingredient transfusion) Blood type:Transfusion time: ______Transfusion reaction1.None2.YesClinic manifestation: ____________________________ Allergic history:1.None2.Yes3.Not clear allergen: __________________________________clinical manifestation: _____________________________________Personal history:Custom living address_: __________________________________________Resident history in endemic disease are_a_: _________________________Smoking: 1.No 2.YesAverage ___pieces per day; about___yearsGiving-up 1.No 2.Yes (Time: _______________________ ) Drinking: 1.No 2.YesAverage ___grams per day; about ___yearsGiving-up 1.No 2.Yes(Time: _________________________ ) Drug abuse:1.No 2.YesDrug names: _______________________________________Marital and obstetrical history:Married age: _________ years old Pregnancy ______________ timesLabor _______________ times(〔.Natural labor: _____ times 2.0perative labor: __________ times3. __________________ Natural abortion: _______________ times4.Artificial abortion: ____ times5. _______________________ P remature labor: ________ times6.stillbirth________________________ t imes)Health status of the Mate:1.Well2.Not fineDetails: _______________________________________________Menstrual history:Menarchal age: ______ Duration ________ d ay Interval ________ daysLast menstrual period: ___________ Menopausal age: _____ years oldAmount of flow: 1.small 2. moderate 3. large Dysmenorrheal: 1. prese nee2.abse nc M enstrual irregularity 1. No 2.YesFamily history: (especially pay atte ntio n to the in fectious and hereditary diseaserelated to the present illness)Father: l.healthy 2.ill: ________ 3.deceased cause: ____________________ Mother:1.healthy 2.ill: ________ 3.deceased cause: ____________________ Others: ________________________________________________________The an terior stateme nt was agreed by the in forma nt.Sig nature of in forma nt: Datetime:Physical ExaminationVital signs:Temperature:0C Blood pressure: / mmHg Pulse: _________ bpm (l.regular 2.irregular ) Respirati on: _______ bpm (l.regular 2.irregular ) General conditions:Development:I.Normal 2.Hypoplasia 3.HyperplasiaNutrition: l.good 2.moderate 3.poor 4.cachexiaFacial expression 1. no rmal 2.acute 3.chro nic other __________________Habitus: l.asthenic type 2.sthenic type 3.ortho-thenic typePosition: l.active 2.positive pulsive 4.other ______________________ Consciousness l .clear 2.somnolence 3.confusion 4.stupor 5.slight coma6. mediate coma7.deep coma8.deliriumCooperation: 1Yes 2.No Gait: l.normal 2.abnormal ______Skin and mucosa:Color: 1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentationSkin eruption:1.No 2.Yes( type: _________ distribution: __________________ ) Subcutaneous bleeding1: .no 2.yes (type: ____ distribution: ______________ )Edema:1. no 2.yes ( location and degree _______________________________ ) Hair: 1.normal 2.abnormal(details _____________________________________ ) Temperature and moisture:normal cold warm dry moist dehydration Liverpalmar : 1.no 2.yes Spider angioma(location: __________________________ ) Others: __________________________________________________________Lymph nodes: enlargement of superficial lymph node:1. no2.yesDescription: _______________________________________________Head:Skull size:1.normal 2.abnormal (description: ___________________________ ) Skull shape:1.normal 2.abnormal(description: __________________________ ) Hair distribution :1.normal 2.abnormal(description: ______________________ ) Others: ___________________________________________________________ Eye: exophthalmos: __________ e yelid: ___________ conjunctiva: _________ sclera: ________________ C ornea: ______________________Pupil: 1.equally round and in size 2.unequal (R _____ mm L _______ mm)Pupil reflex: 1.normal 2.delayed (R___s L___s ) 3.absent (R___L___) others:__________________________________________________________ Ear: Auricle 1.normal 2.desformation (description: _____________________ ) Discharge of external auditory canal:1.no 2.yes (1.left 2.right quality: ___ )Mastoid tenderness 1.no 2.yes (1.left 2.right quality: ________________ )Disturbance of auditory acuity:1.no 2.yes(1.left 2.right description: _____ ) Nose:Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality _____ ) Tenderness over paranasal sinuses:1.no 2.yes (location: ______________ ) Mouth: Lip _____________ Mucosa ____________ T ongue _______________ Teeth:1.normal 2.Agomphiasis 3. Eurodontia 4.others: _____________________Gum :1.normal 2.abnormal (Description __________________________ )Tonsil: __________________________ Pharynx: _____________________Sound: 1.normal 2.hoarseness 3.others: ____________________________ Neck:Neck rigidity 1.no 2.yes ( _____________ transvers fingers)Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distentionTrachea location:1.middle 2.deviation (1.leftward ________ 2.rightward ____ ) Hepatojugular vein reflux: 1. negative 2.positiveThyroid: 1.normal 2.enlarged ______ 3.bruit (1.no 2.yes _______________ )Chest:Chest wall: 1.normal 2.barrel chest 3.prominence or retraction: (left _______ right ___________ P recordial prominence _____________________ ) Percussion pain over sternum1.No 2.YesBreast: 1.Normal 2.ab no rmal _____________________________________Lung: Inspection: respiratory movement 1.normal 2.abnormal ___________ Palpation: vocal tactile fremitus:1. no rmal 2.ab no rmal ____________pleural rubb ing sen sati on :1. no 2.yes ___________________Subcuta neous crepitus sen sati on :1. no 2.yes _____________ Percussion:1resonance 2. Hyperresonance &location _____________3 Flatness&location ________________________________4. dulln ess & location: _____________________________5. tympa ny &location: _____________________________lower border of lung: (detailed percussi on in respiratory disease)midclavicular line : R: ____ i n tercostae L: ____ in tercostaemidaxillary line: R: _______ i n tercostae L: ____ in tercostaescapular li ne: R: ________ i n tercostae L: ____ in tercostaemoveme nt of lower borders:R: ______ cmL: _________ c m Auscultation: Breath ing sound : 1.no rmal 2.ab no rmal ___________Rales:1. no 2.yes _________________________________ Heart: lnspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuseSubxiphoid pulsation: 1.no 2.yesLocati on of apex beat: 1. no rmal 2.shift ( _____in tercosta,dista nee away from left MCL ____ cm) Palpation:Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsationThrill:1. no 2.yes(location: __________ phase: ________________ )Percussion relative dullness border: 1.normal 2.abnormal(Dista nee betwee n An terior Medli ne and left MCL ____ cm) Auscultation: Heart rate: __bpm Rhythm:1.regular 2.irregular ______Heart sound: 1.no rmal 2.abnormal ______________________Extra sound: 1.no 2.S3 3.® 4. opening snapP2 ____________ A _________ Pericardial frictio n soun d:1. no 2.yesMurmur: 1.no 2.yes (location ___________ phase ___________quality _____ i ntensity ________ tran smissio n _________effects of position ________________________________effects of respiration _____________________________Peripheral vascular signs1.None2.paradoxical pulse3.pulsus alternans4. Water hammer pulse5.capillary pulsation6.pulse deficit7.Pistol shot sound8.DuroziezsignAbdomen:Inspection:Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-belly Gastricpattern 1.no 2.yes Intestinal pattern 1.no 2.yesAbdominal vein varicosis 1.no 2.yes(direction: _____________ )Operation scar1.no 2.yes _______________________________ Palpation: 1.soft 2. tensive (location:_____________________________ )Tenderness: 1.no 2.yes(location: _____________________ )Rebound tenderness:1.no 2.yes(location: _______________ )Fluctuation: 1.present 2.abscentSuccussion splash: 1.negative 2.positiveLiver: ______________________________________________Gallbladder:____________________ ______ M urphy sign: ___________Spleen:____________________Kidneys: _____________Abdominal mass: ______Others: _____________________________________________ Percussion:Liver dullness border: 1.normal 2.decreased 3.absentUpper hepatic border:Right Midclavicular Line _______ IntercostaShift dullness:1.negative 2.positive Ascites: _____________ degreePain on percussion in costovertebral area: 1.negative 2.positve ___ Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis4.absence Gurgling sound:1.no 2.yesVascular bruit 1.no 2.yes (location ___________________ ) Genital organ: 1.unexamined 2.normal 3.abnormalAnus and rectum: 1.unexamined 2.normal 3.abnormalSpine and extremities:Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis)3.Tenderness(location _____________________________ )Extremities: 1.normal 2.arthremia & arthrocele (location _________________ )3.Ankylosis (location __________ )4.Aropachy: 1.no 2.yes5.Muscular atrophy (location ______________________ ) Neurological system1:.normal 2.abnormal ______________________________Important examination results before hospitalized Summary of the history: _____________________________________Initial diagnosis: ____________________________________________Recorder:Corrector:。
英语病例报告作文
英语病例报告作文Title: A Case Report: Management of Infectious Mononucleosis in a Young Adult。
Abstract:Infectious mononucleosis (IM), caused by the Epstein-Barr virus (EBV), is a common viral illness characterized by fever, pharyngitis, lymphadenopathy, and fatigue. This case report discusses the presentation, diagnosis, and management of IM in a 22-year-old female.Case Presentation:A 22-year-old female presented to the outpatient clinic with complaints of fever, sore throat, and fatigue for the past week. She reported a recent history of close contact with a friend who had been diagnosed with IM. On examination, she had cervical lymphadenopathy and pharyngeal erythema with exudates. The monospot test waspositive, confirming the diagnosis of IM.Management:The patient was counseled on the nature of IM and advised to rest, maintain hydration, and avoid contact sports due to the risk of splenic rupture. Symptomatic management with acetaminophen for fever and analgesia was recommended. Corticosteroids were not initiated due to the absence of severe complications such as airway obstruction or hemolytic anemia. The patient was educated on the importance of good hand hygiene to prevent transmission of the virus to others.Follow-up:The patient was followed up in the clinic after two weeks. By this time, her fever had resolved, and she reported improvement in sore throat and fatigue. Repeat monospot test was negative, indicating resolution of acute EBV infection. She was advised to gradually resume normal activities but to avoid strenuous exercise for another fewweeks to prevent relapse.Discussion:IM typically presents with a triad of fever, pharyngitis, and lymphadenopathy, often accompanied by fatigue. Diagnosis is confirmed by a positive monospot test or Epstein-Barr virus-specific serology. Management is largely supportive, focusing on symptom relief and prevention of complications. While corticosteroids may be considered in severe cases, they are not routinely recommended due to potential adverse effects and lack of conclusive evidence of benefit. Patients should be educated about the self-limiting nature of the disease and the importance of rest and hydration. Close follow-up is essential to monitor for complications and ensureresolution of symptoms.Conclusion:Infectious mononucleosis is a common viral illness that predominantly affects young adults. Prompt recognition andappropriate management are essential to alleviate symptoms and prevent complications. Clinicians should be familiar with the typical presentation of IM and be prepared to provide supportive care while ensuring patient education and follow-up.。
英语简要病历报告作文
英语简要病历报告作文Title: Patient Medical Report: A Case of Respiratory Infection。
Date: April 16, 2024。
Patient Information:Name: [Patient Name]Age: [Age]Gender: [Gender]Date of Admission: [Date]Admitting Physician: Dr. [Physician Name]Chief Complaint:The patient presents with symptoms of cough, fever, shortness of breath, and fatigue.History of Present Illness:The patient, [Patient Name], a [Age]-year-old [Gender], presented to the emergency department with complaints of cough, fever, shortness of breath, and fatigue for the past five days. The cough was productive, with yellowish-green sputum. The fever was intermittent and associated with chills. The patient also reported experiencing mild chest pain exacerbated by coughing.Past Medical History:The patient has a past medical history significant for asthma, for which they use an inhaler as needed. There are no known allergies to medications.Medications:The patient takes [Medication Name] for asthma asneeded.Social History:The patient is a non-smoker and denies any history of alcohol or illicit drug use. They work as a [Occupation] and have no recent travel history.Family History:There is no significant family history of respiratory illnesses.Physical Examination:On physical examination, the patient was febrile with a temperature of [Temperature], tachycardic with a heart rate of [Heart Rate], and tachypneic with a respiratory rate of [Respiratory Rate]. Oxygen saturation was [Oxygen Saturation]% on room air. Lung auscultation revealed coarse crackles in the lower lung fields bilaterally. There was no evidence of cyanosis, clubbing, or peripheral edema. 。
英文病例汇报范文
英文病历文章病例写作是医生日常的工作。
Associated symptoms 相关症状 Nausea, vomiting*2, sweating, dizzy（恶心、呕吐2次、出汗、眩晕） 1997:external chest tightness and dyspnea initially controlled atenolol. 1997年：出现胸外疼痛与呼吸困难，最终经服atenolol控制。
4/12 symptoms worse, exercise tolerance 200 yards on flat, limited by chest pain 4月12日，症状加重，受胸痛限制，仅耐受平地行走200码 No rest pain, no orthopnoea, no PND 无静息时疼痛，无端坐呼吸、无阵发性夜间呼吸困难Risk factors危险因素 Hypertension-no高血压：无 Smoking-20 cigarettes per day for 16 years 吸烟：16年来每天20支 Diabetes-no糖尿病：无 Cholesterol-never checked胆固醇：未查Ischemic heart disease-angina, previous MI缺血性心脏病：心绞痛、有心肌梗死病史 PMH(past medical history)过去史 1963: appendectomy 1963年：阑尾切除手术 1972: duodenal ulcer, no symptoms since1972年：十二指肠溃疡，之后无症状 1986: myocardial infarction, full recovery / No subsequent investigation1986年：心肌梗死，完全恢复，无随访 1989: gout quiescent on treatment1989年：痛风治疗期间症状静止 No diabetes, hypertension, rheumatic heart disease, tuberculosis, epilepsy, asthma, jaundice, cerebrovascular disease.无糖尿病、高血压、风湿性心脏病、结核病、癫痫、哮喘、黄疸、脑血管疾病 S/E(systems inquiry)系统回顾General 一般情况 Fatigue lately, appetite unchanged, weight stable, no sweats or pruritus, sleeping well 最近有疲劳感，食欲无改变，体重稳定，无出汗或骚痒，睡眠佳。
英文病例报告作文范文
英文病例报告作文范文Case Report: Unusual Stomach Trouble.Man, 45, keeps saying his stomach hurts and he vomits sometimes. He's been like this for half a year, even after trying different meds. He hasn't changed his eating or lifestyle, so what's the problem? When we checked him out, his stomach area was a bit tender, but nothing else unusual.The lab tests showed his liver enzymes were up and he had a bit of anemia. The ultrasound of his belly showed his stomach wall was thicker than normal, like he might have chronic gastritis. But when we did an endoscopy, we saw something weird: there were little sores all over his stomach lining. It didn't look like a regular ulcer.We thought of a few other possibilities: maybe it's Crohn's disease or an autoimmune problem with his stomach. Or could it be eosinophilic gastroenteritis? Since his symptoms were so unusual and the regular treatments didn'twork, we decided to do a biopsy. And guess what? It showed there were a lot of eosinophils in his stomach lining, which means he has eosinophilic gastroenteritis.After starting him on corticosteroids, he felt much better in just two weeks. His stomach pain went away and he didn't vomit as much. When we checked his stomach again three months later, all the sores had healed up. It was a relief to see the treatment worked so well.This case really shows you can't always trust first impressions. Even if a patient's symptoms seem like a common problem, they might be something else entirely. It's always worth doing a thorough investigation to get theright diagnosis and the right treatment.。