June 5, 2010
Our 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: schizophrenia
Treatment/advice: 1. Olanzapine 5 mg Bid.
2. He should follow up in out-patient department 1
week later to regulate(add?) dose of Olanzapine.
3. His current condition permits travel now, but
under medical escort.
4. He should be monitored by relation or caregiver
for regular use of medication after back to UK. In
this case, there is no need to be admitted into
hospital for therapy. If there is none to look after
him for medication taking, admission of hospital is
advised 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 afternoon
Blood 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 tabs
3. L-Glutamine, Sodium Gualenate Granules
4. Aripiprozole tabs
Hope above information will be helpful to you.
Writing Skills of Case Report in English 在医学刊物上发表的病例报告实际上是开始从事医学写作的最好的方法之一。病例报告的撰写,首先要做好题目的选择,肯定要选择与自己专业有关的临床工作,并能提出你认为是很感兴趣的,在概念上、临床上以及理论上存在的棘手问题。通常文字不超过3000字(包括参考文献和附录在内)。绝大多数的病例报告所采用的书写格式,类似于临床研究报告,应该包括:引言、病例叙述、讨论和结论。本文所采用的文章是从2004年英国LANCET杂志中摘录。 1、引言 引言部分要简短明了,应介绍与报告相关的主要临床和概念上的难题,说明病例的重要性,报道的原因,若可能的话,应引证一些最新的综述资料,并能简明地概括出所涉及到的资料内容。在时态上,由于陈述的是客观事实,故运用一般现在时。如: 2、病例叙述 病例叙述的宗旨就是让读者了解病例,明确全部相关结果。病例的叙述通常要
按照时间先后顺序排列,这一部分所涉及到的资料内容包括以下:①病人现有的体症和症状,主诉和病痛。②医学史及相关家史(如糖尿病、心脏病等)。③社会史,诸如吸烟、饮酒和吸食毒品等。④服用过的药物。⑤体检和化验的突出结果。⑥鉴别诊断或考虑诊断。⑦最后诊断。⑧治疗和治疗后结果。通常仅需要提供检查和化验的阳性结果。不过有个别杂志需要提供全面详尽的检验和程序结果。列出化验的正常值范围和不正常的检验结果。在时态的运用上,由于陈述病人过去健康状况和治疗情况,故采用一般过去时。
3、讨论 讨论部分就是要解释病例叙述中不明确的一些情况,并提供对结果的解释。例如,报道肝酶升高,但未发现显著的肝功能异常,给读者讲明为何肝酶升高。在讨论部分的时态运用上,由于提供的是自己现在的推断和观点,故采用一般现在时。如:
[临床类型] 疗反应和预后有一定指导意义。临床上常见的类型有偏执型、单纯型、青春型的紧张型。此外，尚有其他类型。 一、偏执型（Paranoid type）:又称妄想型。本型最多见。发病年龄多在中年（25～35），起病缓慢或亚急性起病，症状以妄想为主，关系和被害妄想多见，次为夸大、自罪、影响、钟情和嫉妒妄想等。妄想可单独存在，也可伴有以幻听为主的幻觉。情感障碍表面上可不明显，智力通常不受影响。患者的注意和意志往往增强，尤以有被害妄想者为著，警惕、多疑且敏感。在幻觉妄想影响下，患者开始时保持沉默，以冷静眼光观察周围动静，以后疑惑心情逐渐加重，可发生积极的反抗，如反复向有关单位控诉或请求保护，严重时甚至发生伤人或杀人。患者也可能感到已成为“众矢之的”，自己已无力反抗的心境下，不得已采取消极的自伤或自杀行为。因而此型患者容易引起社会治安问题。病程经过缓慢，发病数年后，在相当长时期内工作能力尚能保持，人格变化轻微。患者若隐瞒自己表现或者说强调理由时，往往不易早期发现，以致诊断因难。
[病例] 34岁，已婚，工程师，因怀疑被毒害半年入院。病前个性：孤僻、多疑、沉默、敏感。平素健康，无重病史。母患精神病已20年。 少食，怀疑单位领导存心与他作对，每次在单位进餐后均有头昏、手胀、喉塞。疑是领导布置在食物中放毒加害于他。为寻找“解毒剂”，翻阅很多医学书籍，买了“海藻精”，食后自觉很有效，近一月来，怀疑领导串通医务室医生用“中子射线”控制其思想和行为，有时听到“中子射线”与他对话，评论他“老实，知识丰富”，命令他“不许反抗”。走在街上发觉“处处有人跟踪”。疑毒剂失效，买了两只馒头送防疫站化验。在家一提及单位事即很激动，指责家人“你们都不知道，当心上他们的当！”。吸烟加多，满面愁容，同事劝慰则更反感。到处求医，查肝功、心电图、拍胸片，认为身体已被搞垮。近日连续写控告信，并去公安局要求保护。 意识清楚，智力正常，言答切题，表情紧张，所谈多为上述内容，
HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL Hospitalization Records for None-operation Division Division: __________ Ward: __________ Bed: _________ Case No. ___________ Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________ History of Present Illness: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
精神分裂症 病历摘要 场景：心理卫生科门诊 病人资料：女性，21岁，大学生 主诉：怀疑有人议论自己1月，怀疑被人害，听到语声1周 现病史： 患者前三月因没入选学生会，闷闷不乐，总说因为自己思想脏才落选，反复洗头、洗衣物，有时半夜起来到卫生间清洗，经常清洗数小时，有时看到同学们说话，就认为在议论自己没当选，走路要避开熟人，上课时老师看自己的眼神都含有嘲笑的含义，近一周加重，认为竞选时的对手和老师串通好设计自己，对面寝室有同学负责监视自己，有时候能听到脑子里有声音在说“你真笨，你太脏了”，自己想什么事情，声音就说什么。情绪低，总一个人躲在寝室里哭泣，说别人都不理解自己。病程中睡眠差，饮食欠佳。学校老师及父母带病人就诊。 既往史： 1. 2岁时曾患中耳炎； 2.无外伤史；无手术史； 3.无肝炎史，无结核病史，无糖尿病史；否认高血压，冠心病史； 4.无药物及食物过敏史； 个人史： 1.生于吉林市，系第二胎，足月顺产，病前性格敏感多疑，孤僻胆小； 2.无烟、酒及其他不良嗜好； 3.月经史：13； 4.无药物及食物过敏史； 家族史： 姑姑曾被诊断为“神经官能症” 体格检查 生命体征：T：36.7℃P: 76次/分R:18次/分Bp:115/65mmHg 发育正常，营养良好，神志清楚，检查欠合作。全身皮肤无黄染、皮疹，全身淋巴结无肿大，头颅无畸形，胸廓对称，呼吸运动对称，两肺呼吸音清晰，未闻及干、湿罗音，心前区无隆起，心界不大，心率76次/分，腹平软，无压痛及反跳痛，肝、脾未触及，腹部无移动性浊音，肠鸣音正常，肢体运动、感觉正常，腱反射正常，未引出病理反射，无脑膜刺激征。植物神经系统未见异常。 精神检查：意识清晰，接触被动，注意力不集中，东张西望，表情紧张，对周围环境怀有戒心，情感反应欠适切，矛盾情感，拥抱母亲，流泪，又说母亲和学校是一伙的，有言语性幻听，说“脑子里总有个女人说我笨，让我去找老师谈”。援引观念，被害妄想，被洞悉感，内容荒谬，有泛化倾向，如自诉：“对面寝室总有人监视我，也看不到人”“今天报纸上都暗示我了”。智力正常，定向力正常，自知力缺失，不承认自己有毛病，是被别人害的。 患者关心的问题 1、这个医生值不值得信赖？我的感受能不能和他谈？ 2、会不会和他们一起害我？ SP需扮演的角色任务(sp模拟要点) 接诊地点：心理卫生科门诊 患者描述：拟模拟的年龄范围19-23岁，女性，大学生，衣着外表符合上述社会角色。 患者行为态度（一般表现）：家人陪同步入诊室，接触被动，注意力不能长时间集中，东张
精神分裂症案例分析 12社2 120114018 李纪丹 精神分裂症患者是一类特殊的群体，很多的家属和朋友在面对家人异常行为表现的时候，不知道患者是处在一种病态的状态之下，希望能够通过解释和讲道理帮助患者减轻症状，但是往往不能如愿，患者在这种病态之下很难能够听进别人的话，对自己的状态也不是很清楚，自知力比较差，需要家属主动要求患者就医才能帮助患者改善症状。通过《犯罪心理》中里奥.詹金斯的案例进行分析。 一、一般情况介绍 里奥.詹金斯男性三十岁左右曾在疾病控制中心任实验助理 二、主要症状表现 里奥左臂曾患带状疱疹，对其注射疫苗进行治疗后因药效原因产生瘙痒感。医生对其解释是药物正常反应，药效过后就会转好。但是里奥坚持认为医生在注射疫苗时添加了蟑螂幼虫，并且医生们在合谋置他于死地。 在药效过后仍产生幻觉，看见自己手臂皮肤内有蟑螂在蠕动。并且坚信一切都是国家和政府的阴谋，不相信医生的诊断。曾绑架新闻调查记者想让其报道自己体内的虫子，揭露阴谋。失败后，又绑架一名科学家。曾抽出自己的血并认为自己的血是黑色的，自己生了病。当科学家指出血是正常的红色时，里奥认为是科学家污染了样本。并且在科学家指出他可能精神方面有些问题时，狂怒将科学家杀害。 曾经将自己手臂皮肤割开为了取出在其中爬行的虫子。在餐厅会认为饮用水都有问题，已经被政府动了手脚，目的是让所有人被感染。坚信自己正在被国家追杀，因为自己正努力将国家和政府的阴谋揭露。会将朋友的敲门声幻听成警察上门抓捕的声音。 三、症状分析 根据DSM-IV对精神分裂症的诊断标准来看 特征性症状有妄想、幻觉和明显的紧张状态。并且这些症状均在一个月内有明显表现。 社交或职业功能不良：六个月以前就从原工作单位辞职，没有再次出去工作。表现出自起病以来在显著较长时间内，一个以上重要的方面的功能如工作、人际关系或自我照料明显的较起病前差的多。 病期：病情的持续性表现已有六个月，在这六个月内至少一个月符合特征性症状。 排除心境障碍与分裂性情感障碍：分裂性情感精神障碍及伴有精神病性表现的心境障碍均已排除。因无重性抑郁、躁狂或混合发作同时出现于急性症状期。 排除物质或一般躯体情况：患者并没有滥用某种药物、某种治疗用品，也并不是由于一般躯体情况所致直接生理反应。 根据里奥的症状分析可以确定他确实患有精神分裂症。从精神分裂症的分类来说，里奥属于偏执型精神分裂症。 偏执型又称妄想型，是精神分裂症中最常见的类型。起病较缓慢，发病多在青壮年和中年。里奥发病就在中年时期。一开始表现为多疑敏感，逐渐发展为妄想，妄想可以是系统的也可以是零乱的。在该案例中幻想是较为系统地。有时并伴有幻觉和感知觉综合障碍，其中听幻觉最为常见。该案例中同时出现视物变形和听幻觉。其情感和行为常受幻觉和妄想支配，表现为多疑，甚至出现伤人和自伤行为。在该案例中自伤和伤人行为都有出现。但病人的精神衰退不明显，在不涉及其妄想症状时，其行为、语言和思维无明显异常，故在病发后相当长的时间内，病人可以维持日常生活中。在该案例中，病人甚至先后成功绑架两人，也说明了这点。
CASE REPORT FORM TEMPLATE Version: 6.0 (8 November 2012) PROTOCOL: [INSERT PROTOCOL NUMBER] [INSERT PROTOCOL TITLE] Participant Study Number: Study group:
BASELINE DATA General Instructions for Completion of the Case Report Forms (CRF) Completion of CRFs ? A CRF must be completed for each study participant who is successfully enrolled (received at least one dose of study drug) ?For reasons of confidentiality, the name and initials of the study participant should not appear on the CRF. General ?Please print all entries in BLOCK CAPITAL LETTERS using a black ballpoint pen. ?All text and explanatory comments should be brief. ?Answer every question explicitly; do not use ditto marks. ?Do not leave any question unanswered. If the answer t o a question is unknown, write “NK” (Not Known). If a requested test has not been done, write “ND” (Not Done). If a question is not applicable, write “NA” (Not Applicable). ?Where a choice is requested, cross (X) the appropriate response. Dates and Times ?All date entries must appear in the format DD-MMM-YYYY e.g. 05-May-2009. The month abbreviations are as follows: January = Jan May = May September = Sep February = Feb June = Jun October = Oct March = Mar July = Jul November = Nov April = Apr August = Aug December = Dec In the absence of a precise date for an event or therapy that precedes the participant’s inclusion into the study, a partial date may be recorded by recording “NK” in the fields that are unknown e.g. where the day and month are not clear, the following may be entered into the CRF: N K N K 2 0 0 9 DD MMM YYYY ?All time entries must appear in 24-hour format e.g. 13:00. Entries representing midnight should be recorded as 00:00 with the date of the new day that is starting at that time. Correction of Errors ?Do not overwrite erroneous entries, or use correction fluid or erasers. ?Draw a straight line through the entire erroneous entry without obliterating it. ?Clearly enter the correct value next to the original (erroneous) entry. ?Date and initial the correction. Protocol Number: Page 1 of 15
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４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４小时，向颈与双臂放 https://www.doczj.com/doc/434993489.html,，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）
精神科专业病例一 男，42 岁，已婚 主诉：反复洗手10 年，自笑、伤人毁物 2 个月 现病史：病人10 年前开始每天反复洗手，即使手洗的苍白。有时洗1-2 小时，不洗就心烦，自己无法控制，感到苦恼。洗后心里舒服一些，长期治 疗效果不佳。近 2 个月来，表现行为异常，经常自笑，自言自语，声音低 微，别人无法听清内容，问他说什么？答：“没说什么”。时而发呆，有时无原因的突然砸自己家的窗户，摔手机，打父母。有时不在床上睡觉，在 家地上睡，称周围人都议论他，说“自己想事不用大脑，用小脑想事”，时而磕头，无故的大喊大叫。 既往史：无传染病史及药物过敏史 家族史：阴性 体格检查和神经系统检查均无异常。 精神检查：意识清晰，强迫入病房，衣着不整，生活不能自理，接触被动。问：“为什么不在床上睡觉，在地上睡？”答：“地比床大，地床比木床大，所 以我喜欢在地上睡觉”。问：“为什么打父母？”答：“父母和邻居仪器合伙坏我、议论我。”问：“为什么砸东西？”答：“我也不知道为什么砸的。” 问：“为什么摔手机？”答：“经常听到手机里有人骂我，手机里有窃听器。” 时而自笑。 1. 初步诊断：精神分裂症 2. 诊断依据：（1）无明显诱因缓慢起病，逐渐进展，无缓解期 （2）思维逻辑障碍：地比床大，地床比木床大，所以我喜欢在地 上睡觉 （3）思维内容障碍：关系妄想、被害妄想 （4）情感障碍：自笑 （5）行为异常如冲动行为：无原因的突然砸自己家的窗户，摔东 西等 3.鉴别诊断：强迫症：虽然疾病早期有典型的强迫症的症状，强迫行为，反复洗 手，可以考虑有强迫症的可能，但逐渐出现了精神分裂症的核心症状，思 维内容障碍、逻辑障碍和情感行为障碍，可以排除强迫症 4.进一步检查：（1）头CT 或MRI （2）精神症状（阳性症状）评定量表 5.治疗：（1）抗精神病药物 （2）治疗强迫症药物 （3）ECT 6.现场答辩
General information Name Age Sex Race Nationality Address Occupation Marital status Date of admission Date of record Complainer of history Reliability: Reliable Chief complaint The patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing. History of present illness The patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, w ent swimming again. Now the condition is more serious. He has a high fever with 39℃that is accompanied by shaking chills. He has a bad cough with no-blood sputum. When he takes a deep breath, it even hurts. Past medical history The patient is health before. No history of infective disease. No allergy history of food and drugs. No operative history. No disease history in other system. Personal history He was born in XXX on XXXX and almost always lives in XXX. His living conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient. Family history: His parents are both alive. Physical examination General: T P R BP W H. The patient is a well-developed, well-nourished adult male. HEENT: PERRL, EMOI, small oral aperture. Neck: JVP to angle of jaw, 2+ carotid pulses, full range of motion. Cardiac: RRR, normal S1,S2, distant heart sounds. Chest wall: No subcutaneous emphysema. No tenderness. Thorax: Symmetric bilaterally. Breast: Symmetric bilaterally. Lungs: Respiratory movement is bilaterally asymmetric with the frequency of 24/min. We can hear coarse breathing when listening to a portion of the chest with a stethoscope. There are moist rales on bilateral inferior lung. Heart: Border of the heart is normal. Heart sounds are strong and no splitting. Rate 150/min. No pathological murmurs. Abdomen: Flat and soft. No abdominal wall varicose. There is no rebound tenderness on abdomen or renal region. Liver and spleen are untouched. Skin: No pigmentation. No pitting edema. No skin eruption. Extremities: No articular swelling. All limbs can free move. Genitourinary system: Not examed. Rectum: Not examed. Neural system: Physiological reflexes are existent without pathological ones. Investigation Chest X-ray: Lamellar shadow can be seen in middle and inferior lobe of right lung. The right lung is seriously infected. The volume of useful lung is reduced because of the collection of fluid around the lung.
CASE Medical Number: 682786 General information Name:Wang Runzhen Age: Forty three Sex: Female Race:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500 Date of admission:Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation. Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never undergoing any operation. Infectious history:No history of severe infectious disease.
Nanjing children’s hospital Medical Records for Admisson Ward:321 Bed Number:32178 Medical Number: 696235 General information Name:Son of *** Sex: Male Age: 3 h Birthplace: *** county,Anhui province Race:Han Address:***town,***county,Anhu i province Date of admission:3:31pm Oct 16th,2015 Date of record: 3:31pm Oct 16th,2015 Parents Name: father *** Mother *** Complainer of history: patient’s father Reliability: Reliable Chief complaint: Shortness of breath and moaning for 3h Present illness: The afflicted baby was delivered 3h ago and had instaneous shortness of breath along with obtuse response and moaning.No aspnea or seizure or scream were observed. In local Hospital he received treatment of “naloxone、mezlocillin and Vit K1”, but his symptoms didn’t abate. So the parents took him to our hospital, he was admitted with a diagnosis of “acute respiratory dyspnea syndrome” .Breast feed has not been initiated.He has not vomitted,defecated or urinated since he was born,.
Medical Records for Admission Medical Number: 701721 General information Name:Liu Side Age: Eighty Sex: Male Race:Han Nationality:China Address: NO.**, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: ****** Occupation: Retired Marital status: Married Date of admission: Aug 6th, 2001 Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable Chief complaint: Upper abdominal pain for ten days, hematemesis, hematochezia and unconsciousness for four hours. Present illness: The patient felt upper abdominal pain for about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted as “upper gastrointestine hemorrhage and hemorrhagic shock”. Since the disease coming on, the patient didn’t urinate. Past history The patient is healthy before. No history of infective diseases. No allergy history of food and drugs. Personal history He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs. Family history: His parents have both deads. Physical examination
10月23日首次病程记录 患者:***，男，47岁，以“反复自笑、少语，行为异常反复16年”为主诉入院。1、本病历特点:(1)男性，47岁。(2)现病史:患者于1993年无明显诱因出现懒散，不上班，自语自笑，行为怪异，无故骂人，发脾气，无故称有人议论他。之后多次住我院，诊断“精神分裂症”，一直予氯氮平抗精神病治疗。目前患者服用氯氮平100mg qn，阿立哌唑5mg中10mg晚治疗，近段时间患者拒药，又开始出现以上症状，并称父母不是亲生的。家属要求住院治疗。患者近段时间以来，无明显高热、抽搐、昏迷，无兴奋及情绪低落表现，无精神活性物质依赖，饮食可，睡眠好，大小便正常。(3)既往史：幼时曾患“肾炎”，已愈，具体不详。个人史及家族史无特殊。(4)入院查体:体温: 36.2℃脉搏: 84次/分呼吸: 20次/分血压: 124/60mmHg。神志清楚，发育正常，营养中等,全身浅表淋巴结未触及肿大。颈软，颈静脉无怒张，甲状腺无肿大。双肺呼吸呼吸音清，未闻及干湿性啰音。心界无扩大，心率84次/分，律齐，心音正常，各瓣膜听诊区未闻及病理性杂音。腹平软，无压痛、反跳痛。肝脾未触及。肝、肾区无叩击痛，肠鸣音3-5次/分。双下肢无浮肿，四肢肌力、肌张力正常，生理征存在，病理征未引出。（5）精神科检查：意识清晰，定向力完整，意志力减退，较孤僻，懒散，对生活无要求。接触一般，问必答，未引出错觉、幻觉及感知综
合障碍，情感平淡，对情感刺激缺乏内心体验，未引出思维形式异常，存在非血统妄想，坚信自己是欧洲人，称是自己小时候被拐到南安的，智力正常，无自知力。（6）辅助检查:暂缺。 2、入院诊断:精神分裂症。诊断依据:1.患者在意识清晰下出现意志力减退，情感平淡，非血统妄想。2.病程16年。3.社会功能及自知力受损。鉴别诊断: 1.无器质性疾病症状及体征，排除器质性疾病所致精神障碍。2.无精神活性物质依赖，排除精神活性物质所致精神障碍。3.无明显情感优势表现，排除情感障碍。3、诊疗计划: 1、精神科监护。2、行为、心理治疗。3、氯氮平100mg qn联合阿立哌唑15mg/日，苯海索2mgqd药物治疗。4、请上级医师进一步指示。10月24日***主治医师查房 今早****主治医师查房，患者在病房内表现安静，睡眠饮食可，无头晕、头痛，无心悸、胸闷，无口干、便秘等不适。查体：生命体征平稳。神志清楚，发育正常，营养中等,全身浅表淋巴结未触及肿大。颈软，颈静脉无怒张，甲状腺无肿大。双肺呼吸呼吸音清，未闻及干湿性啰音。心界无扩大，心律齐，心音正常，各瓣膜听诊区未闻及病理性杂音。腹平软，无压痛、反跳痛。肝脾未触及。肝、肾区无叩击痛，肠鸣音3-5次/分。双下肢无浮肿，四肢肌力、肌张力正常，生理征存在，病理征未引出。精神科检查：意识清晰，定向力完整，意志力减退，较孤僻，懒散，对生活无要求。接触一
[临床类型] 精神分裂症根据临床表现，可分为若干类型。分型对估计治疗反应和预后有一定指导意义。临床上常见的类型有偏执型、单纯型、青春型的紧张型。此外，尚有其他类型。 一、偏执型（Paranoid type）:又称妄想型。本型最多见。发病年龄多在中年（25～35），起病缓慢或亚急性起病，症状以妄想为主，关系和被害妄想多见，次为夸大、自罪、影响、钟情和嫉妒妄想等。妄想可单独存在，也可伴有以幻听为主的幻觉。情感障碍表面上可不明显，智力通常不受影响。患者的注意和意志往往增强，尤以有被害妄想者为著，警惕、多疑且敏感。在幻觉妄想影响下，患者开始时保持沉默，以冷静眼光观察周围动静，以后疑惑心情逐渐加重，可发生积极的反抗，如反复向有关单位控诉或请求保护，严重时甚至发生伤人或杀人。患者也可能感到已成为“众矢之的”，自己已无力反抗的心境下，不得已采取消极的自伤或自杀行为。因而此型患者容易引起社会治安问题。病程经过缓慢，发病数年后，在相当长时期内工作能力尚能保持，人格变化轻微。患者若隐瞒自己表现或者说强调理由时，往往不易早期发现，以致诊断因难。 [病例]
患者男性，34岁，已婚，工程师，因怀疑被毒害半年入院。病前个性：孤僻、多疑、沉默、敏感。平素健康，无重病史。母患精神病已20年。 半年前患者在工作中与人发生过学术争论，以后出现失眠、少食，怀疑单位领导存心与他作对，每次在单位进餐后均有头昏、手胀、喉塞。疑是领导布置在食物中放毒加害于他。为寻找“解毒剂”，翻阅很多医学书籍，买了“海藻精”，食后自觉很有效，近一月来，怀疑领导串通医务室医生用“中子射线”控制其思想和行为，有时听到“中子射线”与他对话，评论他“老实，知识丰富”，命令他“不许反抗”。走在街上发觉“处处有人跟踪”。疑毒剂失效，买了两只馒头送防疫站化验。在家一提及单位事即很激动，指责家人“你们都不知道，当心上他们的当！”。吸烟加多，满面愁容，同事劝慰则更反感。到处求医，查肝功、心电图、拍胸片，认为身体已被搞垮。近日连续写控告信，并去公安局要求保护。 身体检查和神经系统检查未发现异常。精神检查，仪态端正，意识清楚，智力正常，言答切题，表情紧张，所谈多为上述内容，但进一步追问却说不出道理，否认有病。
POMR (Problem-Oriented Medical Records)表格式住院病历Biographical data: 一般项目： Name Age Sex Marital status Nativity Race 姓名年龄性别婚否xx民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 主诉 History of present illness 现病史 Past history 既往xx： Previous health status: well ordinary bad Infectious diseases 平素健康状况： 良好一般较差传染病xx Immunizations Allergies: N Y clinical manifestation 预防接种xxxxxx无有临床表现 allergen: Trauma:
Surgery: 过敏原外伤xx手术xx Review of systems: (Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy) 系统回顾： (有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经 过)Respiratory system: 呼吸系统 Sore throat chronic cough sputum hemoptysis wheezing 咽痛慢性咳嗽咳痰咯血哮喘 dyspnea chest pain 呼吸困难胸痛 cadiovascular system: 循环系统 Palpitation dyspnea on exertion hemoptysis syncope 心悸活动后气促咯血晕厥 edema of lower limbs precordial pain hypertention 下肢水肿心前区疼痛高血压 Digestive system: 消化系统 Anorexia sour regurgitation belching nausea vomitting