英文撰寫大病例

1、An English Case HistoryDetails個人資料Name: Joe Bloggs(姓名：喬。伯勞格斯)Date: 1st January 2000（日期：2000年1月1日）Time: 0720(時間：7時20分)Place: A&E（地點：事故與急診登記處）Age: 47 years（年齡：47歲）Sex: male（性別：男）Occupation: HGV(heavy goods vehicle ) driver（職業(yè)：大型貨運卡車司機）PC(presenting complaint)（主訴）4-hour crushing retrosternal chest pain

2、（胸骨后壓榨性疼痛小時）HPC(history of presenting complaint)（現(xiàn)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：胸骨后壓榨性疼痛小時，向頸與雙臂放射，5-10分鐘內(nèi)漸起?。〥uration: persistent since onset（間期：發(fā)病起持續(xù)至今）Severe: “worst pain ever had”（嚴重性：“從未痛得如此厲

3、害過）Relieving/exacerbating factors緩解與惡化因素GTN(glyceryl trinitrate) provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.（硝酸甘油平時能在數(shù)分鐘內(nèi)緩解疼痛，但本次無效，無其它緩解和惡化因素。）Associated symptoms相關(guān)癥狀Nausea, vomiting2, sweating, dizzy（惡心、嘔吐2次、出汗、眩暈）1997:external chest tigh

4、tness and dyspnea initially controlled atenolol.1997年：出現(xiàn)胸外疼痛與呼吸困難，最終經(jīng)服atenolol控制。4/12 symptoms worse, exercise tolerance 200 yards on flat, limited by chest pain4月12日，癥狀加重，受胸痛限制，僅耐受平地行走200碼No rest pain, no orthopnoea, no PND無靜息時疼痛，無端坐呼吸、無陣發(fā)性夜間呼吸困難Risk factors危險因素Hypertension-no高血壓：無Smoking-20 cigare

5、ttes per day for 16 years吸煙：16年來每天20支Diabetes-no糖尿病：無Cholesterol-never checked膽固醇：未查Ischemic heart disease-angina, previous MI缺血性心臟?。盒慕g痛、有心肌梗死病史PMH(past medical history)過去史1963: appendectomy1963年：闌尾切除手術(shù)972: duodenal ulcer, no symptoms since1972年：十二指腸潰瘍，之后無癥狀1986: myocardial infarction, full recovery

6、 / No subsequent investigation1986年：心肌梗死，完全恢復(fù)，無隨訪1989: gout quiescent on treatment1989年：痛風治療期間癥狀靜止No diabetes, hypertension, rheumatic heart disease, tuberculosis, epilepsy, asthma, jaundice, cerebrovascular disease.無糖尿病、高血壓、風濕性心臟病、結(jié)核病、癲癇、哮喘、黃疸、腦血管疾病S/E(systems inquiry)系統(tǒng)回顧General 一般情況Fatigue lately

7、, appetite unchanged, weight stable, no sweats or pruritus, sleeping well最近有疲勞感，食欲無改變，體重穩(wěn)定，無出汗或騷癢，睡眠佳。RS呼吸系統(tǒng)Dyspnea on exertion, particularly uphill, but not limiting; no cough sputum/wheeze勞累時呼吸困難，上坡尤其如此，但無呼吸限制，無咳嗽咳痰、哮喘。GIT gastrointestinal tract胃腸道No current indigestion現(xiàn)無消化不良。No symptoms lile prev

8、ious duodenal ulcer過去無十二指腸潰瘍癥狀。No vomiting/dysphagia/abdominal pain無嘔吐、吞咽困難、腹部疼痛。GUS genitourinary system生殖泌尿道No urinary systems無泌尿道癥狀。NS神經(jīng)系統(tǒng)No headache/syncope無頭痛、暈厥。No dizziness/limb weakness/sensory loss無眩暈、肢體麻木、感覺喪失。No disturberd bision/hearing/smell/speech無視覺、聽力、味覺、嗅覺、語言障礙。MS運動系統(tǒng)No painful gout

9、 for 5 years無痛性痛風5年。No joint pain/stiffness/swelling無關(guān)節(jié)痛、僵硬、腫脹。No disability無傷殘。Skin皮膚No rash/pruritus/bruising無皮疹、瘙癢、青腫。Drug history藥物史Atenolol 100 mg once daily（Atenolol100mg每天1次）GTN as required需要服用硝酸甘油。Not taking aspirin無服用過阿斯匹林。Allergies: penicillin-skin rash過敏反應(yīng)：青霉素皮疹。FH(family history)家族史Fathe

10、r died of “heart attack” at age 53.父親53歲死于“心臟病”。Mother died of old age at 76.母親于76歲去世。SH(social history)社會史Lives with wife who fit and well.妻子健在，與其共同生活。Own house私宅。Completely independent生活全部自理。Smoking 20 cigs/day for many years多年每天抽煙20支。Alcohol: 24 units per week飲酒：每周24個單位。Sexual history: not approp

11、riate性生活：未評價。Overseas travel: not appropriate海外旅游：未評價。Pets: not appropriate寵物：未評價。Occupation: heavy goods vehicle driver職業(yè)：大型貨車卡車司機。O/E(on examination)體檢結(jié)果General 一般情況Unwell, sweaty, clammy, no cyanosis/jaundice一般情況不佳，出汗、皮膚濕冷，無青紫、黃疸。temperature: 37.5體溫37.5。cigarette-stained fingers煙熏手指。no arcus / xa

12、nthomas / xanthelasma無老人弓環(huán)、黃瘤、黃斑瘤。CVS心血管系統(tǒng)Pluse 104 bpm regular, normal character脈搏每分鐘104次，規(guī)則，心音正常。BP110/70 mmHg (right), 112/74 mmHg (left)血壓110/70 mmHg右，112/74 mmHg左。JVP(jugular venous pulse) normal頸靜脈博動正常。No precordial scars /chest deformities無心前區(qū)疤痕、胸廓畸形。Apex beat displaced to anterior axillarys

13、line 6th intercostals space心尖博動向腋前線第6肋間移位。No parasternal heave /thrills 無胸骨旁隆起、震顫。Auscultation: heart sounds normal, but soft pan systolic murmur at apex radiating to axilla聽診：心音正常，但心尖問及收縮前柔和雜音，向腋窩放射。PSM at apex and ejection systolic murmur in aortic area with no radiation心尖問及收縮前柔和雜音，以及主動脈區(qū)噴射性收縮期雜音，

14、無放射。ESM in aortic area收縮期射血雜音。Peripheral pulses: absent right popliteal to dorsails pedis周圍脈搏：右腘窩至足背動脈博動闕如。No sacral or ankle edema無骶部與踝部水腫。RS呼吸系統(tǒng)Trachea central 氣管居中。Respiratory rate15/ min, no respiratory distress呼吸頻率15次/分，無呼吸窘迫。Expansion symmetrical and normal胸廓擴張對稱正常。Vocal fremitus normal 語音震顫正常

15、。Percussion note normal叩擊音正常。Breath sounds vesicular throughout, no added sounds全肺聞及水泡音，無額外音。Abdomen腹部No scars/ veins distension無疤痕、靜脈怒張。Palpation: soft, but tender LIF(left iliac fossa)捫診：腹部柔軟，但有觸痛（左髂前窩）。Percussion note normal叩擊音正常。Auscultation: bowel sounds normal聽診：腸鳴音正常。Genitalia not examined生殖器

16、未檢查。Rectal examination: not performed肛門檢查：未檢查。NS神經(jīng)系統(tǒng)Higher function normal高級神經(jīng)功能正常。Cranial nerves顱神經(jīng): normal第一對顱神經(jīng)：正常。:PERRLA(pupils equal in reaction to light and accomodation)/ normal fundi and visual fields 二對顱神經(jīng)：瞳孔對光調(diào)節(jié)反應(yīng)等大，正常眼底與視野。,: no diplopia / nystagmus第三、四、九顱神經(jīng)：無復(fù)視和眼球震顫。-: normal第五至十二對顱神經(jīng)正常

17、。upper and lower limbs: power, tone, coordination, sensation all normal上下肢：肌力、肌張力、協(xié)調(diào)、感覺正常。Reflexes放射Right右Left左Bideps二頭肌Supinator旋后肌Triceps三頭肌Knee膝蓋Ankle踝Plantar跖Joints and skin： Normal關(guān)節(jié)與皮膚：正常。Summary47-year-old male smoker with a family history and previous history of ischaemic heart disease, pres

18、ents with a 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歲男性，有吸煙史與缺血性心臟病的家族史與過去病史，近