英语大病历模板.doc

英文大病例写作示例时间:2007-06-04 17:19 来源:中国医师协会 作者: 点击: 355 次 撰写大病例是实习医师与住院医师的日常工作，也是上级医师作进一步诊断治疗的原始依据，国外的英文大病例并无统一格式，但是基本内容大致相仿，本节介绍的许多医疗记录的词汇值得借鉴。Details个人资料Name: Joe Bloggs(姓名：乔。伯劳格斯)Date: 1st January 2000（日期：2000年1月1日）Time: 0720(时间：7时20分)Place: A&E（地点：事故与急诊登记处）Age: 47 years（年龄：47岁）Sex: male（性别：男）Occupation: HGV(heavy goods vehicle ) driver（职业：大型货运卡车司机）PC(presenting complaint)（主诉）4-hour crushing retrosternal chest pain（胸骨后压榨性疼痛小时）HPC(history of presenting complaint)（现病史）Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.（起病特征：胸骨后压榨性疼痛小时，向颈与双臂放，5-10分钟内渐起病）Duration: persistent since onset（间期：发病起持续至今）Severe: “worst pain ever had”（严重性：“从未痛得如此厉害过）Relieving/exacerbating factors缓解与恶化因素GTN(glyceryl trinitrate) provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.（硝酸甘油平时能在数分钟内缓解疼痛，但本次无效，无其它缓解和恶化因素。）Associated symptoms相关症状Nausea, vomiting2, 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 pain4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: appendectomy1963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。RS呼吸系统Dyspnea on exertion, particularly uphill, but not limiting; no cough sputum/wheeze劳累时呼吸困难，上坡尤其如此，但无呼吸限制，无咳嗽咳痰、哮喘。GIT gastrointestinal tract胃肠道No current indigestion现无消化不良。No symptoms lile previous duodenal ulcer过去无十二指肠溃疡症状。No vomiting/dysphagia/abdominal pain无呕吐、吞咽困难、腹部疼痛。GUS genitourinary system生殖泌尿道No urinary systems无泌尿道症状。NS神经系统No headache/syncope无头痛、晕厥。No dizziness/limb weakness/sensory loss无眩晕、肢体麻木、感觉丧失。No disturberd bision/hearing/smell/speech无视觉、听力、味觉、嗅觉、语言障碍。MS运动系统No painful gout for 5 years无痛性痛风5年。No joint pain/stiffness/swelling无关节痛、僵硬、肿胀。No disability无伤残。更多内容请参考医学知识网：/english/20070604/，增长医学知识。Skin皮肤No rash/pruritus/bruising无皮疹、瘙痒、青肿。Drug history药物史Atenolol 100 mg once daily（Atenolol100mg每天1次）GTN as required需要服用硝酸甘油。Not taking aspirin无服用过阿斯匹林。Allergies: penicillin-skin rash过敏反应：青霉素皮疹。FH(family history)家族史Father died of “heart attack” at age 53.父亲53岁死于“心脏病”。Mother died of old age at 76.母亲于76岁去世。SH(social history)社会史Lives with wife who fit and well.妻子健在，与其共同生活。Own house私宅。Completely independent生活全部自理。Smoking 20 cigs/day for many years多年每天抽烟20支。Alcohol: 24 units per week饮酒：每周24个单位。Sexual history: not appropriate性生活：未评价。Overseas travel: not appropriate海外旅游：未评价。Pets: not appropriate宠物：未评价。Occupation: heavy goods vehicle driver职业：大型货车卡车司机。O/E(on examination)体检结果General 一般情况Unwell, sweaty, clammy, no cyanosis/jaundice一般情况不佳，出汗、皮肤湿冷，无青紫、黄疸。temperature: 37.5体温37.5。cigarette-stained fingers烟熏手指。no arcus / xanthomas / xanthelasma无老人弓环、黄瘤、黄斑瘤。CVS心血管系统Pluse 104 bpm regular, normal character脉搏每分钟104次，规则，心音正常。BP110/70 mmHg (right), 112/74 mmHg (left)血压110/70 mmHg右，112/74 mmHg左。JVP(jugular venous pulse) normal颈静脉博动正常。No precordial scars /chest deformities无心前区疤痕、胸廓畸形。Apex beat displaced to anterior axillarys line 6th intercostals space心尖博动向腋前线第6肋间移位。No parasternal heave /thrills 无胸骨旁隆起、震颤。Auscultation: heart sounds normal, but soft pan systolic murmur at apex radiating to axilla听诊：心音正常，但心尖问及收缩前柔和杂音，向腋窝放。PSM at apex and ejection systolic murmur in aortic area with no radiation心尖问及收缩前柔和杂音，以及主动脉区喷性收缩期杂音，无放。ESM in aortic area收缩期血杂音。Peripheral pulses: absent right popliteal to dorsails pedis周围脉搏：右腘窝至足背动脉博动阙如。No sacral or ankle edema无骶部与踝部水肿。RS呼吸系统Trachea central 气管居中。Respiratory rate15/ min, no respiratory distress呼吸频率15次/分，无呼吸窘迫。Expansion symmetrical and normal胸廓扩张对称正常。Vocal fremitus normal 语音震颤正常。Percussion note normal叩击音正常。Breath sounds vesicular throughout, no added sounds全肺闻及水泡音，无额外音。Abdomen腹部No scars/ veins distension无疤痕、静脉怒张。Palpation: soft, but tender LIF(left iliac fossa)扪诊：腹部柔软，但有触痛（左髂前窝）。Percussion note normal叩击音正常。Auscultation: bowel sounds normal听诊：肠鸣音正常。Genitalia not examined生殖器未检查。Rectal examination: not performed肛门检查：未检查。NS神经系统Higher function normal高级神经功能正常。Cranial nerves颅神经: normal第一对颅神经：正常。:PERRLA(pupils equal in reaction to light and accomodation)/ normal fundi and visual fields 第二对颅神经：瞳孔对光调节反应等大，正常眼底与视野。,: no diplopia / nystagmus第三、四、九颅神经：无复视和眼球震颤。-: normal第五至十二对颅神经正常。upper and lower limbs: power, tone, coordination, sensation all normal上下肢：肌力、肌张力、协调、感觉正常。Reflexes放Right右Left左Bideps二头肌Supinator旋后肌Triceps三头肌Knee膝盖Ankle踝Plantar跖Joints and skin： Normal关节与皮肤：正常。Summary47-year-old male smoker with a family history and previous history of ischaemic heart disease, presents with s 4-month history of increasing exertional chest pain and a 4-hour history of persistent, severe pain at rest, which is unrelieved by GTN and associated with nausea, vomiting, and sweating. On examination, he has a resting tachycardia and evidence of left ventricular dilatation with a displaced apex beat and possible secondary mitral regurgitation. The most likely diagnosis is acute myocardial infarction.47