精神分裂症 英文病历报告

病例报告英文范文医护英语Title: Case Report: Management of a Complex Surgical Case with Multi-system Involvement.Introduction:Surgical cases with multi-system involvement present unique challenges to the treating healthcare team. This case report outlines the management of a complex surgical case with involvement of multiple organ systems, highlighting the importance of interdisciplinary collaboration and comprehensive preoperative planning.Case Presentation:The patient, a 56-year-old male with a history of hypertension and type 2 diabetes, presented to the emergency department with complaints of severe abdominal pain and distension. Initial evaluation revealed a large abdominal mass with ascites. Computed tomography (CT) scanconfirmed the presence of a large, complex abdominal mass with extension into the retroperitoneum, compressing the adjacent organs and vessels.Diagnostic Workup:The patient underwent a series of diagnostic tests including blood work, imaging studies, and consultations with various specialists. The laboratory tests revealed anemia and elevated liver enzymes. The imaging studies, including CT scan and magnetic resonance imaging (MRI), demonstrated a large mass with heterogeneous enhancement, compressing the adjacent organs and vessels. The mass was suspected to be a malignant neoplasm, possibly originating from the pancreas or adrenal glands.Preoperative Planning:Given the complexity of the case and the involvement of multiple organ systems, a preoperative planning meeting was held with the surgeons, anesthesiologists, intensivists, radiologists, pathologists, and oncology team. The plan wasto perform a laparotomy with excision of the mass, followed by reconstruction of the affected organs and vessels. The anesthesiologists recommended a general anesthetic with invasive monitoring, while the intensivists recommended postoperative admission to the intensive care unit (ICU)for close monitoring.Surgical Procedure:The laparotomy was performed through a midline incision. Intraoperatively, the mass was found to be adherent to multiple organs and vessels, including the liver, spleen, kidney, and inferior vena cava. Careful dissection was performed to separate the mass from the adjacent structures, while preserving the vascular integrity. The mass was successfully excised, and the affected organs were reconstructed using sutures and patches. The patient tolerated the procedure well, and hemostasis was achieved.Postoperative Course:The patient was admitted to the ICU for closemonitoring. Postoperatively, he developed transient respiratory failure and required mechanical ventilation. He also developed wound dehiscence due to the extensive surgical dissection. The ICU team managed the patient's respiratory status and provided wound care. The patient gradually improved and was extubated on the third postoperative day. He was transferred to the general surgical floor on the fifth postoperative day and discharged home on the tenth postoperative day.Pathological Analysis:The pathological examination of the excised mass revealed a poorly differentiated adenocarcinoma, likely originating from the pancreas. The surgical margins were negative for tumor involvement. The patient was referred to the oncology team for further management, including adjuvant chemotherapy and follow-up surveillance.Conclusion:This case report demonstrates the successful managementof a complex surgical case with multi-system involvement. The interdisciplinary collaboration and comprehensive preoperative planning were essential for achieving a successful outcome. The case highlights the importance of a multidisciplinary approach in the management of complex surgical cases, ensuring optimal patient care.。

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.。

关于三个病人病历的报告英语作文英文回答：Patient #1。

Presenting complaint: abdominal pain, nausea, and vomiting.History of present illness: The patient is a 54-year-old male who presents to the emergency department with a 2-day history of severe abdominal pain, nausea, and vomiting. The pain is located in the periumbilical area and is described as sharp and intermittent. He has also experienced several episodes of non-bilious vomiting. The patient has not had any bowel movements or flatus in the past 2 days.Past medical history: The patient has a history of hypertension and hyperlipidemia. He is currently taking lisinopril and atorvastatin.Physical examination: The patient is afebrile and in moderate distress. His abdomen is soft and non-tender to palpation. There is no rebound tenderness or guarding. Bowel sounds are hypoactive.Laboratory tests: The patient's white blood cell count is elevated at 12,000/μL. His liver function tests are normal.Imaging: A CT scan of the abdomen shows a small bowel obstruction in the distal ileum.Diagnosis: Small bowel obstruction.Treatment: The patient is admitted to the hospital and treated with intravenous fluids and antibiotics. He is also placed on a bowel rest regimen.Patient #2。

病例报告英语范文深度解析与中文对照**[English Version]****Case Report: Unusual Manifestations of Acute Appendicitis in a Pediatric Patient****Abstract** This case report presents an unusual case of acute appendicitis in a 12-year-old male patient. The patient presented with atypical symptoms, making the initial diagnosis challenging. The aim of this report is to highlight the importance of clinical suspicion and thorough investigation in diagnosing uncommon presentations of common conditions.**Introduction** Acute appendicitis is a common surgical emergency, typically presenting with right lower quadrant abdominal pain, fever, and leukocytosis. However, atypical presentations are not uncommon, especially in pediatric patients. This case report describes an instance where the classic symptoms were absent, leading to delayed diagnosis.**Case Presentation** A 12-year-old male patient presented to the emergency department with a history ofvague abdominal discomfort for the past three days. Thepain was intermittent and located in the epigastric region, radiating to the back. The patient had no history of fever, vomiting, or changes in bowel habits. Physical examination revealed mild tenderness in the epigastric region, with no rebound tenderness or guarding. Laboratory tests were remarkable for a mildly elevated white blood cell count.Initial differential diagnosis included gastroenteritis, urinary tract infection, and pancreatitis. However, due to persistent abdominal discomfort and the presence of mild leukocytosis, the possibility of appendicitis was entertained. Abdominal ultrasound revealed a distended appendix with peri-appendiceal fluid, confirming the diagnosis of acute appendicitis.**Discussion** This case highlights the challenges in diagnosing acute appendicitis in pediatric patients, especially when the classic symptoms are absent. Clinicians must maintain a high index of suspicion, consideringatypical presentations, especially in children. Detailed history, thorough physical examination, and appropriatediagnostic testing are crucial in making an accurate diagnosis.**Conclusion** Acute appendicitis can present with atypical symptoms in pediatric patients, making diagnosis challenging. Clinicians should be aware of these presentations and utilize diagnostic tools such as ultrasound to aid in the prompt and accurate diagnosis of appendicitis. Prompt surgical intervention is essential to prevent complications and ensure patient recovery.**[Chinese Version]****病例报告：儿童急性阑尾炎的非典型表现****摘要** 本病例报告介绍了一名12岁男性患者的急性阑尾炎非典型表现。

Ref: Mr. FlynnJune 5, 2010Our local doctor in SH led patient to Shanghai Mental Health Center at 2 PM this afternoon then visited psychiatrian there. Following is updated information for the patient. The insured came to Shanghai in Dec of 2009 to study Chinese. In January 2010 the Chinese course finished then he started to live in an apartment alone. He admitted since April of 2010 visual/audio hallucination started. On May 9 he visited psychiatrian in UFH of Shanghai then Olanzapine was administered in out-patient department, until he was admitted there on May 29 for operation of Tibia/fibula fracture. Upon discharge of UFH SH, anti-schizophrenia agent Abilify 5 mg Bid and Clonazapam 2mg QN were ever prescript. Upon enquiry by the psychiatrian in SH Mental Health Center this afternoon, the insured showed state of alert, easy contact. He still complained instructive audio-hallucination and persecutive feeling (delusion). He felt somtimes his thought was fully perspected by others. However, no tendency of violent assaulting or obvious depression were noted. He had no recognization of his condition being sicked.Diagnosis: schizophreniaTreatment/advice: 1. Olanzapine 5 mg Bid.2. He should follow up in out-patient department 1week later to regulate(add?) dose of Olanzapine.3. His current condition permits travel now, butunder medical escort.4. He should be monitored by relation or caregiverfor regular use of medication after back to UK. Inthis case, there is no need to be admitted intohospital for therapy. If there is none to look afterhim for medication taking, admission of hospital isadvised after he is back to UK.After the visit of psychiatrian finished this afternoon, the insured was sent to Changning District Central Hospital for cardiologist visit.There was no discomfort complaint of chest depress or shortness of breath. His vital signs as BP, T, RR, HR and oxygen saturation were in normal range. Heart and lungs (-).ECG of this afternoon: normal.Labs done this afternoonBlood routine: WBC 10800(normal < 10000), with LYM 41%.CK, CK-MB, Tryponin etc were in normal range.Coagulation function tests were basically in normal range.Blood platelet cell: 380000(100000-300000)D-dimmer result was normal.The cardiologist thought his heart condition was stable now, no impression of cardiac ischemia. Then he was prescript Cefuroxime tabs and L-Glutamine, Sodium Gualenate Granules. The cardiologist thought his heart condition would not disturb his travel.The current medications he is taking now:1. Oxycodone/Paracetamol tabs (painkiller)2. Cefuroxime tabs3. L-Glutamine, Sodium Gualenate Granules4. Aripiprozole tabsHope above information will be helpful to you.。

Medical Records for AdmissonMedical Number: 1247717General informationName: Cai Chunwang Age: 47y Date of birth :1965. 2.16 Sex: male Race: HanNationality: ChinaMarriage: married Occupation: worker Identification No. :422103************Address: Huanggang city ,Hubei Phone No.: 138********Complainer of history:Cai Chunwang Reliability: HimselfDate of record: 2013.2.27Chief complaint: Pancytopenia for 2 yearPresent illness: The patient found Pancytopenia at 2011, and he used to be in hospital to take a physical examination which was considered into Myelodysplastic syndrome with a largeprobability . The patient had reexamined hemogram , with obvious pancytopenia .So hegot into the hospital to do the Bone marrow cytology and Immune typing ,which showedthat MDS had aggravated into AML .Now , he has no any bleeding spot in theskin ,without headache 、melena、stomachache and so on. The clinic made it “AML” tobe treated in hospital.During the period of the illness, his mental state is bad ,with a fair appetite and sleep .The stool and urination are both normal, with a hyposthenia. Weight is the same asbefore.Past history: general situation is badSystem review:Respiratory system: No.Circulatory system: NoAlimentary system: NoGenitourinary system: NoHematopoietic system:NoEndocrine system:NoKinetic system:NoNeural system:NoInfectious history: DeniedAllergic history:. NoOperative history: He was once operated on an cholecystectomy.Tauma history: Denied.History of allergy: Denied .History of preventive inoculation] : the national plan for vaccinationPersonal historyMenstrual history:MaleObstetrical history:NoMarriage: married once.Family history:His father and mother are alive and healthy. Denies genetic and infectious diseases in his family.Physical examinationT 37℃, P95 /min, R 20 /min, BP 124/78 mmHg. He is well developed and moderately nourished. Active position. The skin was not stained yellow. Cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged in his neck.HeadCranium: size : normal large small deformity. No coxycephaly squared skull deforming skull. No tenderness mass sunk .Ear: Auricle is normal .No excretions of external auditory canal. No Tenderness of mastoid.Nose: Shape is normal .No nosalala flap obsruction excretions nasal sinus tenderness .Eye: Eyes eyelid、eye ball、Sclera、Pupils and reaction to light are normal.Mouth: Mouth lips is normal .Opening of parotid gland duct: normal .Tongue : normal.Gums: normal .lead line tooth:regular.Tonsils: pharynx: voice: normal.Neck: No resistence.Hepatojugular reflux:(-).thyroid: normal.ChestChest wall: normalThorax : normal.Breast:normal symmetricalLungs : Inspection : movement of respiration : normal .Intercostal space :normal .Palpation : vocal fremitus : normal .pluernal friction rubs: No.Subcutaneous crepitus: No.percussion:resonance.Dusculation: breath regular.Breath sound: normal.Rale: No.Vocal conduction:norma .Plueral friction rubs: No.Heart:Inspection:bulging in precordial region : No.apex impulse:normal. position: normal .Palpation: apex impulse : normal .Thrills :No.Percardial friction rub s:NO.Percussion:relative cardiac outline: normal.Ausculation: heart rate 95bpm/min ,rhythm:regular.Heart sound:S1 normal.S2 normal.S3 No. S4 no. Extra heartsound No. Opening snap others murmurs: N.Pericardial friction rubs no. Peripheral vessals:normal.Abdomen:Inspection: shape normal .Abdominal respiration: existence .Umbilicus: normal protruding excretions others: NO.Palpation: soft.Tenderness: NO.Mass NO.li ver:can’t be touched.gallbladder: can’t be touched.tenderness No.spleen: can’t be touched.Kideny:can’t betouched.tenderness mobility tenderness of ureters: No.Percussion: borders of liver dull:existence .pper borders of liver on right midclavicular line intercostal space shifting dullnessNo. tenderness in renal region No.Ausculation : borhorygmus normal .Gurgling No.vessalbruits No.Extremities: Spine : normal.Spinous process :no.Mobility : normal. Extremeties: normal.Neural system:not found any abnormality.Genitourinary system: not examined.Rectum:not examinedHistory summary1.General information: Cai Chunwang ,male ,47y.2.Chief complaint: Pancytopenia for 2 year.3. past history: general situation is bad, Infectious history: Denied. Allergic history:. No.Operative history:He was once operated on an cholecystectomy. Tauma history: Denied. History of allergy:Denied . Historyof preventive inoculation] : the national plan for vaccination4. Physical examination: T 37℃, P95 /min, R 20 /min, BP 124/78 mmHg. his mental state is bad.Superficial lymph nodes were not found enlarged in his neck. heart rate 95 bpm/min ,rhythm:regular.Heart sound:S1 normal. S2 normal. S3 No. S4 no. shape normal . Abdominal respiration: existence .Umbilicus: normal protruding excretions others: NO. Palpation: soft. Tenderness: NO. Mass NO.liver:can’t be touched. gallbladder: can’t be touched. tenderness No. spleen: can’t be touched.Kideny:can’t be touched. tenderness mobility tenderness of ureters: No. Percussion: borders of liver dull: existence . pper borders of liver on right midclavicular line intercostal space shifting dullness No.tenderness in renal region No. Ausculation : borhorygmus normal . Gurgling No. vessal bruits No.movement of respiration : normal . Intercostal space :normal . Palpation : vocal fremitus : normal .pluernal friction rubs: No. Subcutaneous crepitus: No. percussion: resonance. Dusculation: breath regular. Breath sound: normal. Rale: No. Vocal conduction: norma .5.Specialist case：serious anemia. The skin was not stained yellow. Cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged in his neck.No tenderness of sternum. Ausculation of the heart and lung has not obvious abnormality. Abdomen is soft . Tenderness: NO. Mass NO. liver:can’t be touched. gallbladder: can’t be touched. tenderness No. spleen: can’t be touched. Extremeties are normal .6 . investigation information: one medical record of 2013 year.Impression: AMLSignature: Huang QiulanDate: 2013.2.27。

病历包括：体温检查表，长期医嘱单，临时医嘱单，病史记录，病人入院评估表，护理记录单，精神科宣教，健康指导表，入院须知，精神疾病患者住院知情同意书，体检检查记录表。

病史记录第一次－第三次住院病史摘要患者73年无明显原因精神异常，当时主要猜疑有人在陷害他，吵闹不安，工作不能胜任。

当时由单位及家属陪同到医院就诊，诊断精神分裂症，给予氯丙嗪奋反静等治疗后，缓解后出院，先后于74－76年期间在总院三次住院，均诊断精神分裂症，给予氯丙嗪奋反静治疗，好转出院，85年病情加重，表现为耳闻人语，夜眠差，自言自语，行为紊乱，猜疑，冲动打人，故于85.9－86.4第五次住本院，诊断精神分裂症，给予氯丙嗪氯氮平治疗后出院。

94.9.18－01.10.8，02.6.21－03.1.6住院，诊断精神分裂症，显著缓解后出院。

第四次住院病史（本次09.2.5――）03年1月6日，出院后开始能坚持服药，病情稳定，生活能自理，08年9月病情出现反复，表现：耳闻人语，说党中央有人害他，自称“华国锋”，乱说乱跑，自己写信到公安，告知罪行等。

近一月来病情加重表现，易激惹，企图凶杀，有人害他，要自己自杀，把刀乱舞，影响社区安全，夜眠差等，劝说无效，来医院要求住院治疗。

本次发病以来，舞消极自杀行为，由冲动、外出行为，进食尚可，夜眠差，个人生活尚能自理，大小便正常。

过去史：07年发慢支，痔疮病史，目前无治疗，情绪稳定，未发现器质性疾病，无感染，抽搐，脑外伤，骨折史，无传染病史，有过敏史（青霉素），无输血史，预防接种不祥。

个人史：1、生长发育：排行老五，足月顺产，体健，发育正常2、学习工作情况：适龄上学，学习成绩尚可，65年初中毕业，毕业后在上海电机厂读校，68年毕业留单位工作，能胜任，自73年患病后就未上班，00年12月30日正式退休手续。

3、恋爱婚姻史：无恋爱，婚姻史。

4、病前性格及不良嗜好，个性内向，倔犟，不合群，有吸烟嗜好。

家族史：1、家族成员姓名、性别、年龄、工作状态、疾病2、二系三代精神发作史否认二系三代有精神病疾病史体格检查神清心肺（一）BP120/180MMG辅助检查正在进行中一般情况1、意识，清2、定向：对时间，地点，人物，定向力强（现在是甚么地方？）“精神病医院”（现在几月几日？）“2.6”（我是干什么的？）“医生”3、仪表：欠整4、接触：欠合作5、注意力：欠集中感知1、错觉：未引出（这是甚么？）“钢笔”（对）（这是甚么？）“听诊器”（对）2、幻觉：存在言语性幻听（没有人的时候有人和你讲话吗？）“有的”（什么人？）“确有”（男的女的？）“不清楚”（讲的甚么？）“要害我，你也是来的”3、感知综合障碍：未发现躯体和时间问题思维1、思维联想障碍（你知道为什么住院？）“病发了”（为什么会这样？）“不知道”（这样住院几次）“四次”2、思维逻辑障碍：未发现（谁送过来的）“家人”（知道为什么？）“不知道”（在家干什么？）“作作家务，也没啥”3、思维内容障碍：存在被害妄想，夸大妄想（有人害你）“是的，党中央派人”（家里有人害你吗？）“有的，饭里放毒”（你怎么发现的）“我吃上去感觉不适”（华国锋怎么回事？）“就是我，你不认识”（你多大了）“你看看”（华国锋是干什么的？）“你说呢，自己面子很好，有邓小平、江泽民多人害我，你也是派来的”4、思维属性障碍：未引出（自己不讲你的事，别人会知道吗？）“不会的”（别人的想法你知道吗？）“不会的”（有人跟踪你吗？）“没有”情感：1、根据病人的姿态、动作、言语、面部表情等外在表现，表情平淡，情感反应不协调。