COPD英文病历

慢性阻塞性肺疾病（COPD）英⽂内容可以⼿触上下移动Chronic obstructive pulmonary disease or COPD is a gradual loss of your ability to breathe affectively. Normally as you inhale, air moves freely through your trachea or windpipe, then through large tubes called bronchi, smaller tubes called bronchioles, and finally into tiny sacs called alveoli.Small blood vessels called capillaries surround your alveoli, oxygen from the air you breathe passes into your capillaries, then carbon dioxide from your body passes out your capillaries into your alveoli, so that your lungs can get rid of it when you exhale.Normally your airways and alveoli are flexible and spraying. When you inhale, each air sac inflates like a small balloon, when you exhale, the sacs deflate. Smoking is leading cause of COPD, however, it may also be caused by long exposure to other lung irritants, such as air pollution, chemical fumes, and dust. If you have COPD, you have the two main conditions that make up the disease, emphysema and chronic bronchitis.In emphysema, your airways and air sacs lose their flexibility making it hard for them to expand and contract, emphysema destroys some of your air sac walls, leading to fewer larger sacs that provide less area to absorb oxygen from the air you breathe. The symptoms of emphysema include: wheezing, shortness of breath, and tightness in your chest. With chronic bronchitis, damage inside your airways causes the lining to swell, thicken and make mucus. You develop a persistent cough as your body attempts to get rid of the extra mucus.The symptoms of chronic bronchitis include an ongoing cough that produces a lot of mucus, shortness of breath and frequent respiratory infections. The damage done to your lungs by COPD can not be reversed, and there is no cure for the disease. However, treatment can slow the progress of the your disease and help you feel better, the common treatments are quitting smoking, use of inhaled medicines to open your airways and reduce swelling, antibiotics for bronchitis caused by bacterial infection, oxygen therapy for those with advanced COPD and severely low level of oxygen in their blood, and surgery such as ablectomy and lung volume reduction surgery to remove non-functioning air sacs.The best way to prevent yourself from getting COPD is to never smoke. If you are a smoker, quitting smoking reduces the chance you develop COPD, you can also limit your exposure to chemicals, fumes and dusts that may cause COPD.。

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:。

肺脓肿病历报道范文英文回答：Patient Name: [Patient's Name]Age: [Patient's Age]Gender: [Patient's Gender]Date of Admission: [Admission Date]Date of Discharge: [Discharge Date]Chief Complaint:The patient presented with complaints of persistent cough, fever, and difficulty in breathing.Present Illness:The patient had been experiencing a cough with yellowish sputum for the past two weeks. The cough was accompanied by high-grade fever and chills. The patient also reported shortness of breath and chest pain. The symptoms progressively worsened, leading to the patient seeking medical attention.Past Medical History:The patient had a history of chronic obstructive pulmonary disease (COPD) and was a chronic smoker for the past 20 years. The patient had no previous episodes of lung infections or hospitalizations.Physical Examination:On examination, the patient appeared acutely ill. Vital signs revealed an elevated b ody temperature of 39.2°C, tachycardia, and increased respiratory rate. Auscultation of the chest revealed decreased breath sounds and crackles over the right lower lung field.Investigations:Chest X-ray revealed a consolidation in the right lower lobe of the lung. Laboratory investigations showed an elevated white blood cell count and increased inflammatory markers.Diagnosis:Based on the clinical presentation, physical examination findings, and radiological investigations, the patient was diagnosed with a lung abscess.Treatment:The patient was started on broad-spectrum antibiotics to cover both aerobic and anaerobic organisms. Chest physiotherapy was initiated to aid in the clearance of secretions. The patient was closely monitored for any signs of worsening infection or complications.Outcome:The patient showed gradual improvement in symptoms with the ongoing treatment. Repeat chest X-ray showed a reduction in the size of the lung abscess. The patient's fever subsided, and the cough and shortness of breath gradually resolved. The patient was discharged on oral antibiotics with follow-up scheduled in two weeks.中文回答：患者姓名，[患者姓名]年龄，[患者年龄]性别，[患者性别]入院日期，[入院日期]出院日期，[出院日期]主诉：患者主诉持续咳嗽、发热和呼吸困难。

慢性阻塞性肺病病历书写模板患者信息- 姓名：[患者姓名]- 年龄：[患者年龄]- 性别：[患者性别]- 住址：[患者住址]- 职业：[患者职业]主要症状- 过去几个月出现进行性加重的咳嗽- 咳痰，并且咳嗽咳痰持续时间超过2个月- 呼吸困难，尤其在活动或体力消耗增加时- 胸闷或胸痛- 频繁的感染，例如肺炎或支气管炎既往病史- [患者既往病史，例如：高血压、糖尿病等]家族史- [患者家族成员是否有慢性阻塞性肺病或其他呼吸系统疾病] 检查结果- 肺功能检查：[如有，请注明检查结果]- 胸部X射线/CT扫描：[如有，请注明检查结果]- 动脉血氧饱和度测定：[如有，请注明结果]- 其他检查：[如有其他相关检查，请注明结果]诊断- 慢性阻塞性肺病（COPD）治疗方案- 吸烟戒断：[提醒患者尽快戒烟]- 支持性治疗：[描述支持性治疗措施，如合适的饮食、适量运动等]- 药物治疗：[描述药物治疗方案，如支气管扩张剂、抗炎药等] - 呼吸康复训练：[提醒患者参加呼吸康复训练]- 定期复诊：[建议患者定期复诊，监测病情和调整治疗方案]病程观察- 症状观察：[记录患者症状的变化，如有新的症状或症状加重，请注明]- 检查观察：[记录患者检查结果的变化，如有需要，请注明再次检查的日期和结果]- 治疗观察：[记录患者治疗方案的效果，如有需要，请调整治疗方案]注意事项- 避免吸烟和二手烟- 避免接触有害气体和粉尘- 注意呼吸道感染的预防- 定期复诊和随访以上是慢性阻塞性肺病病历书写模板的主要内容，根据具体情况和需要，可以作相应调整和补充。