医学英语-英文病例-范文

医学英语-英文病例-范文

Case History

Name: Meretrix Gender: Female

Age: 40 Occupation: Nurse

Birth Place: Washington DC Marital Status: Married

Address: #112, Main Avenue, Washington DC

Reliability: Reliable Supplier: Patient herself

Date of Admission: 10am, Aug. 6th, 2006Date of Record: Aug.

6th, 2006

C.C.:

Palpitation and breathlessness after exertion for 7 years;

edema of lower extremities for 4 days

H.P.I.:

The patient got palpitation and breathlessness after

overexertion and going upstairs alleviating after having a rest 7

years ago. Then she saw her doctor, and the roentgenography

showed an enlargement of the heart; but it was so negligible that

she was not treated. She came to Washington 5 years ago

because of frequent bad colds due to bad weather conditions

with strong cough which didn’t ameliorate with the

disappearance of the palpitation and breathlessness but with

orthopnea at night. She was once hospitalized with an injection

of penicillin and glucose and had a rest of 2 weeks, thus

propelling the symptoms. She complains of a flatulence without

edema of lower extremities in the recent 2 years. One month ago,

she was admitted to our hospital with sore throat, cough,

hemoptysis, palpitation, breathlessness, and orthopnea due to a

bad cold resulting from exhaustion. Antitussive and penicillin

have been employed but it was in vain. Edema of lower extremities came into being in the recent 3 days or so; urine is

little with a dark color; feces are not amorphous with once a day;

dyspepsia and nausea are overt. Digitalis has not been used and

good in mental status with infrequent insomnia.

P.H.:

The patient has been and is weak with frequent sore throat

since her childhood. She

got malaria 11 years ago with a medication of quinine and

thus symptoms disappeared a week after with a recurrence and

a similar treatment resulting in good outcome; no migrant rash

was found. No histories of allergy to drug or food, of trauma or

surgery, of blood transfusion. And we are not informed of a

history of inoculation.

Pers. H.:

The patient was a Shanghaier and came to Washington DC 5

years ago. No visiting history to other places. She was an

undergraduate. The patient is a housewife with a gasto of reading.

She is quiet and not addicted to smoke or wine. She

F.H.:

She married at the age of 24 and her husband is 39 now.

Parents, a girl aged 10, and a boy aged 6 are all living and well.

Mens. H.:

6

14——40

28

P.E.:

T. 38.0℃. P. 70. R. 30. B.P. 100/70mmHg.

The patient stayed in bed in semi-reclining position. She

looked actually ill, but remained conscious, and was well oriented

to time, place, and person. Skin and Lymph Node: N.A.D. (No abnormality detected.)

Head: There was flaring of the nares, but otherwise normal.

Neck: Negative.

Chest: Excursion decreased on the right side of the chest.

Trachea in the midline. Heart: Disseminated rales in the fundi of

the two lungs, especially the right lung. Lungs: Slightly increased

fremitus, dull percussion note, diminished breath sound, and fine

moist inspiratory rales were present on the right bases. The rest

of the chest showed nothing special.

Abdomen: Soft. Liver felt 1.5 cm below L.C.M. (lower costal

margin) on the mid-clavicular line. Spleen not felt. Murphy’s

sign weakly positive, with

no palpable gall-bladder. No tenderness or mass elsewhere.

Spine, Extremities, Rectum and External Genitalia: Nothing

remarkable. Neurological Reflexes: Physiological reflexes normal.

No pathological reflexes elicited. O.P.D. Lab. Findings (Out-Patient

Department Laboratory Findings):

Blood:

W.B.C. 14,000/cmm

D.B.C. P.M.N.82%, Lymph. 16%, M.1%

R.B.C. 3,900,000/cmm

Hgb. 11 gm

Feces:

Dark yellow, slightly cloudy, acidic.

Density 1.019

Protein (+)

Glucose (-)

W.B.C. 5/HP

Major Diagnostic Evidence:

1.History of streptococcal infection and a weak body. 2.Symptoms and signs of heart failure and pulmonary edema.

3.W.B.C. of 14,000 with 82% polys.

Impression:

1. Rheumatic valvular disease.

Mitral stenosis complicated with mitral regurgitation

Atrial fibrillation

Grade III heart failure

2. Acute onset of a chronic tonsillitis.

Date: Aug. 6th, 2006Attending Physician____________