英文病历(发热待查)

医学英语病历范文Medical RecordPatient Information:Name: John SmithAge: 45Gender: MaleDate of admission: [Date]Date of birth: [Date]Weight: [Weight]Height: [Height]Chief complaint:Mr. Smith presents with a severe headache that has been ongoing for the past two days.History of present illness:The patient reports experiencing a sudden onset of throbbing headache, localized primarily on the left side of his head. The pain is aggravated by physical exertion and is accompanied by nausea and sensitivity to light and sound. The patient denies any recent head trauma or sinus congestion. Over-the-counter pain relievers have provided minimal relief.Medical history:Mr. Smith has a history of hypertension, for which he takes medication. He does not have any known allergies, and there is no family history of migraines or neurological disorders.Social history:The patient is a smoker, consuming approximately 10 cigarettes per day. He drinks alcohol in moderation, primarily on social occasions. He denies any illicit drug use. His occupation involves long hours of computer work.Physical examination:On examination, the patient appears to be in mild distress due to the headache. His vital signs are within normal limits. Neurological examination reveals no focal deficits, and his cranial nerves appear to be intact. There is no evidence of meningeal irritation. His neck is supple, and there is no nuchal rigidity. The remainder of the physical examination is unremarkable. Laboratory tests:Blood tests, including a complete blood count and comprehensive metabolic panel, were performed. All results were within normal limits.Imaging studies:A brain MRI was ordered to rule out any structural abnormalities. The scan revealed no evidence of intracranial hemorrhage, mass, or other abnormalities.Assessment and plan:Mr. Smith is presenting with a severe headache consistent with a migraine without aura. He will be prescribed a triptan medication for acute management of his headache. He will also be counseled on lifestyle modifications, including smoking cessation and stress reduction techniques. A follow-up appointment will be scheduled in two weeks to evaluate the effectiveness of the treatment plan.Additionally, the patient is advised to seek immediate medical attention if his symptoms worsen or if he develops any new neurological symptoms.Signature: [Physician's Name]Date: [Date]。

Name: Aiyu SunAge: 37Gender: FemaleRace: the Han nationalityBirth Place: HongHu CityMarital Status: MarriedOccupation: FarmerAddress: Group Six, WeiGou Village, FengKou Town, HongHu City,Hubei Province Informant: Aiyu SunDate of admission: June 3 , 2010Date of history taken: June 3 , 2010Chief Complaint:Feeling hot, palpitation, polyphagia for four months, fever forfive daysHistory of Present Illness:The patient felt hot, palpitation, polyphagia in Feburary, without obivious motivation. The symptoms appeared with shivering of hands and the head, irritability, exophthalmos of both eye balls gradually. The symptoms appeared without complaints of diarrhea, magersucht, hoarseness,blurred vision and so on. The patient did not go to receive any medical treatment. From April, the symptoms above became more severe, with powerless of limbs. The patient went to local hospital on 27th, April. Examination result: FT3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC6.11*109/L, N7.01*109/L; ALT 52u/L↑, AST 41u/L. The patient was diagnosed as “hyperthyroidism, cacergasia of liver”. The patient took Tapazole 5mg tid , propanolol, inosine, drugs for liver protection and WBC raising from then on. The symptoms described above was relievedafter taking these medicines. On 12nd, May, the bood routine was still normal: WBC 5.8*109/L, N 3.1*109/L. But five days ago, without obivious motivation, the patient had a pharynx ache, fever, which was highest at 38.7°C,with headache and catarrhus. The pati ent was diagnosed as “upper respiratory infection, hyperthyroidism, agranulemia” and gave antiinfection therapy. But the fever continued, the therapy effect was not well. The patient comes to our hospital today. The blood routine today is WBC 0.15*109/L↓, N0*109/L↓↓↓, and the outpatient department receives the patient to our ward as“hyperthyroidism, agranulemia”.During the course of disease, sleep and psyche were acceptable. Polyphagia lasted. Stool and urine were as usual. Physical strength descended. Weight was stable.Past History:General Health Status: good √moderate poorInfectious Disease: √no yes(if any, please write down date of onset, brief diagnostic and therapeutic, course )Typhoid fever Dysentery Malaria Schistosomiasis Leptospirosis Tuberculosis Epidemic hemorrhagic fever othersAllergic history: √no yes (clinical manifestation: allergen: ) Trauma and/or operation history: √no yes- 1 -Review of Symptoms:Respiratory system: √no yesRepeated pharyngeal pain:chronic cough: expectoration: Hemoptysis: asthma: dyspnea: chest pain:Circulatory system:√no yesPalpitation: exertional dyspnea: cyanosis: hemoptysis: Edema of lower extremities: chest pain: syncope: hypertension:Digestive system:√no yesAnorexia: dysphagia: sour regurgitation: eructation: nausea: Emesis: melena: abdominal pain: diarrhea: hematemesis: Hematochezia: jaundice:Urinary system:√no yesLumbar pain: urinary frequency: urinary urgency: dysuria: oliguria: Polyuria: retention of urine: incontinence of urine: hematuria: Pyuria: nocturia: puffy face:Hematopoietic system:√no yesFatigue: dizziness: gingival hemorrhage: epistaxis: subcutaneous hemorrhage:Metabolic and endocrine system:√no yesBulimia: anorexia: hot intolerance: hyperhidrosis: cold intolerance: Polydipsia: amenorrhea: tremor of hands: character change: Marked obesity: marked emaciation: hirsutism: alopecia: Hyperpigmentation: sexual function change: impotence: amenorrhea:Musculoskeletal system:√no yesMigrating arthralgia: arthralgia: artrcocele: arthremia: Dysarthrosis: myalgia: muscular atrophy:Neurological system:√no yesDizziness: headache: paresthesia: hypomnesis: Visual disturbance: Insomnia: somnolence: syncope: convulsion:Disturbance of consciousness: paralysis: vertigo:Personal history:Resident history in endemic disease area:√no yesSmoking: √no yes: about___yearsDrinking:√no occasional frequent: about____years average____ml/day Others:In April 2009, the patient was diagnosed as “polyp of vocal cord” in our hospital and got medicine thrapy.Menstrual history:Menarchal age: 21 years old duration__5__days/ interval_30_daysLast menstrual period: 2010.5.1 menopausal age: _13_years oldAmount of flow: small √moderate largedysmenorrheal: p resence √absenceMarital and obstetrical history:Married age: 21 years old pregnancy_4__times natural labour: 3 timesAbortion: 2 times premature labour: 0 times still birth: 0 timesDystocia and its course:0Family history:(pay attention to the infectious and hereditary disease related to the present illness)Father: √healthy ill: deceased cause:Mother: √healthy ill: deceased cause:Others: noPhysical ExaminationGeneral conditions:Temperature: 37.3°C pulse:88 times per minute (√regular irregular)Blood pressure:139/84mmHg respiration: 20 times per minute(√regular irregular) Development: √normal HypoplasiaNutrition: good √moderate poor cachexiaFacial expression: √normal acute chronic other( )Posture: √active semi-reclining position other ( )Mental status:√clear confusion somnolence delirium comaGait: √normal abnormal cooperation: √yes noSkin and mucosa:Color:√normal pale cyanosis stained yellow pigmentationrash:√no yes: (type: distribution: )subcutan eous hemorrhage: √no yes (type: distribution: )Hair distribution: √normal hypertrichosis oligotrichosisalopecial(location: ) Temperature and moisture: √normal cold warm dry moist dehydrationEdema: √no yes ( location and degree )Liver palmar : √no yes spider angioma:√no yes (location: )Others: noLymph nodes:enlargement of superfacial lymph node: √no yes (location and description: ) Head: without abnormityCranium: without abnormityEye: exophthalmos: exophthalmos of both eye ballseyelid: without descensusconjunctiva: without edemasclera: without stained yellowCornea: √normal abnormal ( od os )Pupil:√equally round and equal in size: unequal (od os )Pupil reflex: √normal delayed (od os ) absent (od os ) others:Ear: di scharge of external auditory canal:√normal (left right quality: ) Mastoid tenderness : no (left right )disturbance of rough hearing test: yes √noNose: flaring of alae nasi:√no yesstuffy discharge:√no yestenderness over paranasal sinuses: √no ye s(location: )Mouth: lip: redMucosa: without ulcerationTongue: stretched tongue is in the middleGum: nomalTonsil: Ⅰ°enlargement of both sidesPharynx: congestionsound: √normal hoarseness teeth: √normal absent carieNeck:neck rigidit y √no yes (distance between sternum and mandible:______transvers fingers) Carotid artery: √normal pulsation increased pulsation marked distention Trachea:√middle deviation (leftward rightward )Hepatojugular vein reflux: negativeThyroid: normal √enla rged bruitChest:Chest wall: √normal barrel chest prominence or retraction: (left right ) Precordial prominence: √no yespercussion pain over sternum:√no yesBreast: normalLung:Inspection: normal respiratory movementPalpation:vocal tactile fremitus: normalpleural rubbing sensation: √no yesSubcutaneous crepitus sensation:√no yesPercussion: √resonanc dullness Flatness Hyperresonance tympany lower border of lung: (detailed percussion in respiratory disease) midclavicular line : right:_6__cm left:_6__cmmidaxillary line: right:_8__cm left:_8__cmscapular line: right:_10__cm left:_10__cmAuscultation: breathing sound :√normal abnormalRales: √no yes (moist dry ) location:Heart:Inspection:apical pulsation:√normal unseen increase diffuse sSubxiphoid pulsation: √no yesLocation of apex beat:√normal shift (distance away from leftMCL___cm) Palpation:apical pulsation: √normal lifting apex impulse negative pulsationThrill:√no yes (location: ) phase:Percussion:relative dullness border:√Normal decreased absent increaseR(cm) line L(cm)2 Ⅱ 22 Ⅲ 43 Ⅳ 6Ⅴ8Distance between anterior median line and MCL 8.5cm Auscultation: heart rate: 88bpm rhythm: regularheart sound:√normal abnormalextra s ound:√no S3 gallop S4 opening snap:murmur: √no yes:location timing quality intensity transmission:effects of position:effects of respiration:P2 = A2 pericardial friction sound:√no yesPeripheral vascular sign: √no yes: paradoxical pulse pu lsus alternansWater hammer pulse capillary pulsationpulse deficit Pistol shot sound Duroziez sign Abdomen:Inspection: shape: √normal distention scaphoid frog-bellygastric pattern:√no yes visible intestinal peristalsis:√no yesabdominal vein v aricose: √no yes (direction: )operation scar:√no yesPalpation: √soft guarding (location: )Tenderness: √no yes (location: )rebound tenderness:√no yes (location: )fluctuation succussion splash:√no yesliver: can’t be touch ed under the ribsgallbladder: can’t be touched under the ribsMurphy sign: negativespleen: can’t be touched under the ribskidneys: kidney zones without Percussion painabdominal mass :can’t be touchedPercussion: liver dullness border: √normal decreased absen tUpper hepatic border locates at right midclavicularline5_intercostal spaceShift dullness: negativePain on percussion in costovertebral area:√no yes R L Auscultation: bowel sounds : √normal hyperperistalsis hypoperistalsis absenceVascular bruit :√no yes (location )Genital organ: √unexamined normal abnormalAnus and rectum:√unexamined normal abnormalSpine and extremities:Spine: √normal deformity (kyphosis lordosis scoliosis )Tenderness (location )Extremities: √normal arthremia(loc ation ) arthrocele (location ) Ankylosis (location ) aropachy Muscular tenderness(location ) muscular atrophy (location )Neurological system:Abdominal reflex++ cremasteric reflex- knee reflex++Kernig`s sign(R- L- ) Brudzinski`s sign:(R- L- ) Babinski sign (R- L- )Opphenheim sign(R- L- )Gordon sign (R- L- ) Lasegue sign (R- L- ) Others: noImportant exam results from out-patient service: X-ray number:no27th, April, local hospital: FT3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC 6.11*109/L, N 7.01*109/L;ALT 52u/L↑, AST 41u/L.12nd, May, local hospital: Blood-rt: WBC 5.8*109/L, N 3.1*109/L3rd, June, our hospital: Blood-rt: WBC 0.15*109/L↓, N0*109/L↓↓↓Summary of case history:1 Patient Aiyu Sun, female, 37 years old.2 Chief Complaint: Feeling hot, palpitation, polyphagia for four months, fever for five days3 Past History: General health status was moderate. In April 2009, the patient was diagnosed as “polyp of vocal cord” in our hospital and got medicine thrapy. The patient deny history of TB, HBV, schistosome infection, DM, HBP, heart diseases and other special diseases. The patient deny history of allergy, trama, surgery operation and blood transfusion.4 Physical Examination: T37.3°C P88 times per minute BP:139/84mmHg R: 20 times per minute. Normal development, moderate nutrition, active posture, clear mental status, cooperated examination. There is no yellow stained in the skin and mucosa. There is no enlargement of superfacial lymph nodes. Head shape and cranium are normal. There is exophthalmos of both eye balls. Both tonsils are Ⅰ°enlarged. Pharynx is congestion. No neck rigidity. Trachea is in the middle. Thyroid of both sides isⅡ°enlarged, without vascular bruit. Breathing sound of the lung is normal. And there is no rale. Heart rhythm is regular, without any obvious murmur at each valve zone. Abdomen shape is normal. Abdomen is soft, without tenderness or rebound tenderness. Liver and spleen can’t be touched under the ribs. Kidney zones are without percussion pain. Both hands are shivering. There is no edema of both lower limbs.5 exam results:27th, April, local hospital: FT3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC 6.11*109/L,N 7.01*109/L; ALT 52u/L↑, AST 41u/L.12nd, May, local hospital: Blood-rt: WBC 5.8*109/L, N 3.1*109/L;3rd, June, our hospital: Blood-rt: WBC 0.15*109/L↓, N0*109/L↓↓↓Primary diagnosis:1 Hyperthyroidism2 Agranulemia:(1)Induced by drugs;(2)Hematopoietic system diseases?(such as aplastic anemia,MDS,leukemia etc.)3 Acute upper respiratory infection4 Other diseases which cause fever: such as other infections, connective tissue diseases etc.Corrected diagnosis (date 2010.6.4)1 Hyperthyroidism2 Agranulemia: Induced by drugs3 Acute upper respiratory infectionsignature:writer: Yanling LiangRevisor:。

soap英文病历Patient Name: James SmithAge: 45Gender: MaleNationality: AmericanChief Complaint:The patient presents with a persistent rash on his arms and legs, accompanied by itching. He states that the rash appeared suddenly and has been present for the past two weeks. The patient is seeking medical attention to determine the cause and appropriate treatment for his condition.Medical History:The patient has a history of allergies, specifically to dust mites and pollen. He has not experienced any previous skin conditions or rashes. The patient is not currently taking any medications and has no known drug allergies.Present Illness:The patient reports that the rash initially started as small, red bumps on his arms and legs. Over time, the bumps have increased in size and have become itchy. He denies any associated symptoms, such as fever, fatigue, or joint pain. The patient has used over-the-counter hydrocortisone cream for itch relief, but it has provided only temporary relief.Physical Examination:On examination, the patient has multiple erythematous patches with raised edges on his arms and legs. The affected areas appear dry and slightly scaly. There are no signs of oozing or crusting. The rash is symmetrical and does not extend to the trunk or face. There is no lymphadenopathy or other abnormal findings on examination.Differential Diagnosis:1. Contact dermatitis: Contact with an irritant or allergen may cause a localized rash with itching and erythema.2. Atopic dermatitis: Chronic inflammatory skin condition characterized by itching, redness, and dryness of the skin.3. Psoriasis: Autoimmune disorder causing thick, scaly patches on the skin.4. Scabies: Infestation of the skin by microscopic mites causing intense itching and a characteristic rash.Investigations:1. Skin scraping and microscopic examination: To rule out scabies infestation.2. Allergy testing: To determine if the rash is related to an allergic reaction.Treatment Plan:1. Topical steroid cream: Prescribe a stronger topical steroid cream to reduce inflammation and relieve itching. Instruct the patient to apply a thin layer to the affected areas twice daily for two weeks.2. Moisturizers: Recommend using non-fragrance, hypoallergenic moisturizers to keep the skin hydrated and prevent dryness.3. Avoid triggers: Advise the patient to avoid known allergens or irritants that may exacerbate the rash.4. Follow-up: Schedule a follow-up appointment in two weeks to evaluate the effectiveness of the treatment and make any necessary adjustments.Patient Education:1. Review proper application of the topical steroid cream and discuss potential side effects, such as skin thinning and discoloration.2. Emphasize the importance of avoiding scratching to prevent infection and further skin damage.3. Discuss the potential triggers for allergic reactions and provide recommendations for allergen avoidance, such as using fragrance-free products and washing clothes with mild detergents.Prognosis:With appropriate treatment and adherence to the prescribed regimen, the prognosis for this patient is good. The symptoms should improve within two weeks with resolution of the rash and relief from itching. However, it is important to monitor the patient for any signs of exacerbation or recurrence.。

Discharge SummaryMRN: 394722Patient’s name: Mr. Kilcher MartinAge: 43y/oDate of admissio:24/04/2010Date of discharge: 01/05/2010Diagnosis on admission: 1.Interstitial Pneumonia2.UTI ( urinary tract infection)3. Secondary fungus infectionDiagnosis at discharge: 1. Interstitial Pneumonia2.UTI ( urinary tract infection)3. Secondary fungus infectionMedical history and treatment summary:The patient was admitted to hospital with 4 days history of frequency & urgency of urinary and 20 days history of repeated cough and fever.PE on admission:T37.1。

C, R18/min, P68/min, BP128/60mmHgThe patient was alert with normal comprehension.Lips: no indication of cyanosisLungs: harsh resperatory sound was available, no ralesHeart: regular heart beat rate, strong cardiac sound, heart murmurs (-)The patient was given treatment of anti-infection, anti-virus, eliminating phlegm, improving immunity and anti-fungus infection upon admission. The lungs infection improved, UTI and secondary fungus infection completely released after the treatment above mentioned. The patient was discharged on 01/05/2010 because the end of journy was due.Laboratoray tests:22/04/2010 Huaxi Hospital●CT scan of chest showed:Scattered rough massiveness shadows were seen at upper lobe, middle lobe, and the bottom of the right lung. The sign at upper lobe was worse.●Urinary Rt.: occult blood (+), WBC (+)●Blood Rt: N 92.5%.24/04/2010 No. 4 People’s Hospital, ChongqingStool Rt: Fungus(+)Blood tests: K+ 3.46mmol/LUrinary Rt: WBC481/ul, RBC23/ul, Hb (++), SPE (++)30/04/2010 No. 4 People’s Hospital, ChongqingUrinary Rt: normalStool Rt: normalBlood Rt: normalCT scan of chest showed a sign of inflammation at right lung with mild pleural effusion, which indicated that the lung infection was at the stage of absorbtion.Ultrasound of heart: no indication of pericardial effusion.Others: normalOn the date of discharge, the patient had cough occationally. No fever, chest pain, no urinary frequency and urgency. The patient stayed in a normal mental staus with good appetite. Normal bowels movement and passing water. The patient was allawed to leave hospital on account of the end of the journey was due.Suggestions by treating doctor:Dringking WaterAvoid tiredRecieptName: Kilcher Martin。

标准英⽂病历-晕厥待查[Case Discussion]Loss of consciousness of unknown origin1.General information: Zhang XX, 78 years old female .2.Chief complaint: Episodic syncope for five years.3.Medical History Summary: In the past five years, Miss Zhang had transient, self-limited loss of consciousness lasting for 1-3minutes seven times, followed by prompt recovery. The attacks occurred at different positions and preceding activities including walking, standing and sitting. Prodromal symptoms were palpitation , nausea and sweating, but not occurred every time. Every time she fell down, she was accompanied with urinary incontinence, but no fecal incontinence except twice, no spasm. Low blood pressure was captured twice but EKG was normal. Holter monitors revealed long R-R interphase up to 2.66s. ECHO revealed normal heart structure with normal EF. She had medical history of coronary heart disease for 15 years with two stent placed in the coronary artery. Hypertension for 10 years. Physical examination was nagetive, whereas the heart rate was 71bpm and blood pressure was 140/70mmHg on admission. Laboratory test was negative.4.Five years ago, one day afternoon when the lady stood up and walked just several steps, she suddenly felt obvious palpation, dizziness and profuse sweating. About 30s later, she lost consciousness and fell down, with urinary incontinence, but no fecal incontinence. Four minutes later, the lady restored consciousness without obvious discomfort. She was immediately sent to hospital but the doctor said her electrocardiogram (EKG) was normal, so she didn’t take further test or medication. Four years ago, when the lady woke up and walked towards restroom one day morning, she suddenly lost consciousness and fell down without any prodrome. About 1 minute later, she recovered and found her urinary incontinence. This time she didn’t go to see the doctor. At the year of 2012, she lost consciousness twice. The first episode occurred at 7th, March when she had been standing in line for nearly 5 minutes. She suddenly felt palpitation, and then lost consciousness very soon. She fell down and hurt head badly. About three minutes later, she recovered with urinary incontinence and obvious headache. Later on, she was sent to hospital by ambulance, and her blood pressure was 70/45mmHg. As she hurts head badly, the crania magnetic resonance imaging (MRI) showed subcutaneous hematoma whereas EKG was still normal. Besides these, doctor also assigned her a 24-hour dynamic electrocardiogram (Holter)monitors and reported maximum heart rates as 105bpm at 08:46:13 13rd, Mar, minimum heart rates as 44bpm at 09:03:44 12th, Mar and max R-R interphase as 1.66s due to atrial premature beats fallen to conduct. Half a year later, 28th, September, the lady fell down again due to suddenly loss of conscious without any prodrome, and she was admitted by the Hospital. She was assigned a Holter monitors which reported a similar results as the one of March, a 24-hour blood pressure monitor which showed average blood pressure of 134/66mmHg while the highest pressure was 176/87mmHg and the lowest one was 89/37mmHg. Her electroencephalogram was normal and cervical vertebra MRI reported protrusion of intervertebral disc. She was discharged with diagnose of syncope of unknown origin. Two years ago, the year of 2013, the old lady fell down twice. The former episode occurred after she had been standing answering telephone for nearly 20 minutes, whereas the latter occurred when she was washing dishes. She felt obvious nausea, dizziness and sweating in the former episode, but no obvious discomfort in the latter one. The lady recovered with urinary incontinence in both these two events and fecal incontinence only in the former one. After the latter one, the lady was assigned another Holter monitors which revealed similar results like before. What’s more, she also received a Transcranial Doppler (TCD) which found no obvious stenosis in her intracranial artery. The latest time this lady lost consciousness was at 05th, March，2015，when she was sitting in the waiting room at the Outpatient. Before she fell down, she felt obvious nausea, dizziness and sweating again. And about 2 minutes later, she recovered, founding herself urinary and fecal incontinence. After her recovery, her blood pressure was75/55mmHg, blood glucose was 6.54mmol/L and EKG was still normal, according to her outpatient medical records. Several days after that, she received another Holter monitors once again and got a similar result. Today, in order to find out why she lost consciousness repeatedly, she was admitted. During the past five years, she felt no change of her mental state, appetite and sleep, and her weight also kept stable.5.Past Medical History: Coronary heart disease for 15years with two snt; Hypertension for 20 years;6.Physical examination: T 36.5℃, P 71/min, R 18/min, BP 140/70mmHg. She is well developed. Active position. Her consciousness was clear. No bulge and no abnormal impulse or thrills in carotid artery. The lung was normal. No rales were heard. The point of heart maximum impulse was normal. No pericardial friction sound. Border ofthe heart was normal. Heart sounds were strong and no splitting. Rate 71/min. Cardiac rhythm was regular. No murmurs were heard. No abdominal wall varicose. Gastrointestinal type or peristalses were not seen. Tenderness was not seen. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluid thrill negative. Shifting dullness negative. No vascular murmurs. No other positive signs.7.Investigation information: EKG(08th,May.2015): sinus rhythm, heart rate 71/min, QS waveform was seen at III and A VF leads.Impression: Loss of consciousness (unknown origin)Coronary heart diseaseHypertensionHyperlipidemiaFatty liver。

英语病历范文Patient Information:- Name: [Not Specified]- Age: [Not Specified]- Date: [Not Specified]- Doctor: [Not Specified]Chief Complaint:The patient presents with a persistent cough, accompanied by mild fever and body aches for the past three days.History of Present Illness:The patient first noticed the symptoms on [Date], with a dry cough that gradually worsened. The fever started as low-grade but has been increasing, reaching up to 38.5 degrees Celsius.Past Medical History:The patient has no significant past medical history. No previous hospitalizations or chronic illnesses are reported.Medications:The patient has not taken any medications for the current illness, nor are they on any regular medication.Allergies:No known allergies to medications or environmental factors.Physical Examination:Vital signs: Temperature 38.3°C, Puls e 92 bpm, Respiratory rate 20 breaths per minute, Blood pressure 120/80 mmHg. The patient appears fatigued but in no acute distress. Lungs are clear to auscultation with no wheezing or crackles. The throat is slightly red without exudates.Assessment:Based on the symptoms and physical examination, the patient is likely suffering from a viral upper respiratory infection.Plan:1. Hydration and rest are recommended.2. Over-the-counter fever reducers and cough suppressants may be used as needed for symptomatic relief.3. If symptoms persist or worsen, the patient should return for further evaluation and potential testing for influenza or COVID-19.Follow-up:The patient is advised to follow up in one week if symptoms have not improved or if new symptoms develop.Instructions:- Increase fluid intake to prevent dehydration.- Avoid contact with others to prevent the spread of the infection.- Monitor for signs of worsening condition, such as difficulty breathing, persistent high fever, or chest pain.Note: This is a hypothetical patient case and should not be used as a substitute for professional medical advice, diagnosis, or treatment.。