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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]。
英语病历报告作文格式Patient Medical Record Report.Patient Information:Full Name: John Doe.Gender: Male.Age: 45。
Address: 123 Main Street, City, State, Country.Contact Number: +1234567890。
Presenting Complaints:Mr. Doe presented with complaints of persistent chest pain, shortness of breath, and fatigue for the past two months. He reported a history of smoking for the past 20years and occasional alcohol consumption. There was no history of similar episodes in the past.Physical Examination:General: Mr. Doe appeared to be in moderate distress. His skin was pale, and there were no signs of jaundice or cyanosis.Cardiovascular: Heart rate was elevated at 100 beats per minute with irregular rhythm. Auscultation revealed a murmur in the mitral area.Respiratory: Breath sounds were diminished in the left lung base with evidence of crackles.Abdominal: Soft, non-tender abdomen with no organomegaly.Neurological: No focal neurological deficits were noted.Diagnostic Tests:Electrocardiogram (ECG): Showed irregular heartbeat with evidence of atrial fibrillation.Chest X-ray: Revealed enlarged heart with pulmonary congestion.Echocardiogram: Confirmed the presence of mitral valve regurgitation.Medical History:Mr. Doe had a history of hypertension for the past five years, which was well-controlled with medication. He had no known allergies to any medications. His family history was unremarkable for any cardiovascular diseases.Differential Diagnosis:Coronary Artery Disease (CAD)。
英语病历作文格式模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。
A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。
A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。
A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。
History taking of coughPatient Name : Mrs. PennyAge: 35History conducted by: Doctor ZhangHistory conducted on: 31/08/2014 4:00pm.Source: The patient gives her own history and appears to be a reliablesourceChief complaint: Productive coughHistory of present illnessMrs. Penny is a 40-year-old yellow Chinese female who works in No.1 middle school as a teacher. She has been noticing worsening cough for 1 week,which is from dry to be with white sputum, and the volume of sputum isabout 1 tea spoon per time. There is no accompanying chest pain or anyother symptoms. The cough is relatively constant throughout the day andnight but does vary in severity and it is severest right after waking upin the morning. Changing body positions, especially standing up, worsens the cough. Mrs. Penny finds no ways to relief it. She had a cold and a39°C fever one week ago, and then started to cough as a result. She hasbeen taken several days off due to the cough and sought for anotherdoctor ’ s help in a community hospital 3 days ago, but those prescribedpenicillin and antitussive did n’ t work.Past medical history1.Mrs. Penny once had tonsillitis at 6 years old, acceptingpenicillin with dose unknown.2.At 35 years old, she received appendectomy after appendicitis withoutblood transfusion.3.She has been experienced chronic cough for 5 years,which is associatedwith cold whether especially winter days.And the cough will last for3 months each year. She didn’t look for any treatments or drugs.MedicationsShe took penicillin 3 days ago. No known drugs allergies.Family historyMrs. Penny ’s son is 12 years old and he is healthy.Social HistoryMrs. Penny is a Chinese teacher in No.1 middle school. She is married and has a 12-year-old son. She denies past or present tobacco and alcohol use.Review of systemsGeneral-as is indicated in the history of present illness, no fevers orchills; appetite not assessed; denies fatigue, malaise, weight lossSkin–denies rashes and skin lesions anywhere on her body.HEENT:Head – Denies headache; denies dizziness or syncopeEars – denies difficulty or changes in her hearing, denies tinnitusEyes – denies problems or changes in her vision; denies blurredvision; denies seeing spotsNose – Denies congestion or rhinorrheaThroat–denies dysphagia or sore throatCardiovascular–denies chest pain; denies palpitationPulmonary – denies shortness of breath,endorses cough with white sputum Gastrointestinal–denies abdominal pain; denies diarrhea orconstipation; denies bloody bowel movementGenitourinary – denies dysuria; denies increased frequency or urgencyof urinationNeurologic – denies numbness and tingling; denies paresthesias Musculoskeletal – denies any muscle or joint painHematopoietic – denies easy bruisingPsychiatric–denies depression, anxiety, mental disturbance,difficulty sleeping, suicidal ideation, hallucinations, paranoiaEndocrine–denies polyuria,polydipsia,polyphagia, weight change, heat or cold intoleranceHeme/Lymphatic: denies easy or excessive bruising, history ofblood transfusions, anemia, bleeding disorder, adenopathy, chills,sweats Allergic/Immunologic: denies urticarial, hay fever, frequenturinary tract infections; denies HIV high risk behaviorsReferences:1. 2. 3. 4.。
英文病历报告作文模板Patient Information- Name: [Patient's Full Name]- Gender: [Male/Female]- Age: [Patient's age]- Date of Admission: [MM/DD/YYYY]Chief ComplaintThe patient presented with [specific symptoms/complaints] which started [duration].History of Present IllnessThe patient reported [detailed description ofsymptoms/complaints]. The symptoms worsened over the past [duration]. The patient experienced [associated symptoms] and tried [any self-medication or home remedies] but noticed no improvement. There was no history of trauma or injury.Past Medical HistoryThe patient has a history of [chronic/acute medical conditions, if any] which includes [specific conditions]. The patient has taken[previous medications/treatments] for these conditions.Social HistoryThe patient has a [specific occupation] and lives in [specific area]. The patient does [specific habits] such as smoking or drinking alcohol [frequency]. There is no significant family medical history.Physical Examination- Vital Signs:- Blood Pressure: [value] mmHg- Heart Rate: [value] bpm- Respiratory Rate: [value] bpm- Temperature: [value]C- General Appearance:The patient appears [general appearance of the patient].- Systemic Examination:- Cardiovascular: [specific findings]- Respiratory: [specific findings]- Gastrointestinal: [specific findings]- Neurological: [specific findings]- Musculoskeletal: [specific findings]Laboratory and Imaging Findings- Blood Test Results:- Complete Blood Count: [values]- Biochemical Profile: [values]- Others: [specific findings]- Imaging:- [Specific imaging tests performed]- Results: [specific findings]DiagnosisAfter evaluating the patient's medical history, physical examination, and laboratory/imaging findings, the following diagnosis was made:[Primary Diagnosis]Treatment and ManagementThe patient was started on [specific treatment plan] which includes [medications, therapies, or procedures]. The patient wasadvised to [specific instructions] and scheduled for [follow-up tests/appointments, if any].Follow-upThe patient will be followed up in [specific time frame] to assess the response to treatment and manage any complications that may arise. The patient was given contact information for any urgent concerns or changes in symptoms.Discussion and ConclusionThis case report highlights the presentation, evaluation, and management of a patient with [specific condition]. The patient's symptoms were appropriately addressed through a systematic approach involving history taking, physical examination, and laboratory/imaging investigations. The provided treatment plan aims to address the underlying cause and improve the patient's overall well-being. Continuous monitoring and follow-up will guide further management decisions.Note: This medical case report is fictional and serves as a template for educational purposes. Any resemblance to actualpatients is purely coincidental.。
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:。
英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。
英文版病例报告作文Patient: Mr. Smith。
Age: 45。
Gender: Male。
Complaint: Severe chest pain and shortness of breath。
History of Present Illness: Mr. Smith presented to the emergency room with complaints of severe chest pain and shortness of breath. He described the pain as crushing and radiating to his left arm. He also reported feeling lightheaded and dizzy. The symptoms started suddenly while he was at work and have been ongoing for the past 30 minutes.Past Medical History: Mr. Smith has a history of hypertension and hyperlipidemia. He is a smoker and admits to occasional alcohol consumption. He has no known drugallergies.Family History: His father had a history of myocardial infarction at the age of 50. His mother is alive and well with no significant medical history.Social History: Mr. Smith works as a sales manager and is under a lot of stress. He smokes a pack of cigarettes per day and drinks alcohol socially. He is currently single and lives alone.Physical Examination: On examination, Mr. Smith appeared diaphoretic and in distress. His blood pressure was 180/100 mmHg, heart rate was 110 beats per minute, and respiratory rate was 24 breaths per minute. His oxygen saturation was 92% on room air. Cardiac auscultation revealed muffled heart sounds and bilateral crackles on lung auscultation.Diagnostic Tests: ECG showed ST-segment elevation in leads II, III, and aVF, consistent with an inferior myocardial infarction. Cardiac enzymes were elevated,confirming the diagnosis of acute myocardial infarction.Treatment: Mr. Smith was immediately started on aspirin, clopidogrel, and heparin. He was also given nitroglycerinfor chest pain and oxygen supplementation to maintain oxygen saturation above 94%. He was then taken for emergent cardiac catheterization and percutaneous coronary intervention.Follow-up: Mr. Smith's symptoms improved after the intervention, and he was discharged home on dualantiplatelet therapy, statin, and beta-blocker. He was advised to quit smoking and reduce alcohol consumption. He was also referred to a cardiac rehabilitation program for further management.Outcome: Mr. Smith's condition improved significantly after the intervention, and he has been compliant with his medications and lifestyle modifications. He has not had any recurrent chest pain or shortness of breath since the hospitalization.。
【前言】：病历的书写，不管情不情愿，是我们见习、实习生活中十分重要的一部分。
中文病历是基本要求，英文病历是附加题。
对于书写英文病历，首先要明确自己的目的和期望。
比如说通过书写英文病例学习专业词汇，与国际接轨；将来考虑出国；好奇心使然等等。
有此意愿的同学大可好好思考一下，给自己一个理由和动力。
协和有写英文病历的传统，但还没有统一、固定的格式。
不过格式不外乎：国外原版和中文病例对译版。
目前黄老师坚持，如果我们要写英文病历，就要跟国际化的要求接轨，所以支持原格式和写作习惯。
但具体格式，都因医院、因人而异。
故总结中注重的是—提出基本框架，规范术语。
大家可作适合自己的微调。
A COMPLETE History & PhysicalHISTORYDate and Time of history:Identifying Data：Source of history, source of referral:Reliability:Chief complaints:quote the patient’s complaints, like “My stomach hurts and I feel awful”; or report their goals, like “I have come for my regular check-up”;[BATES’]patient’s age, a brief but relevant past medical history, a few words about what problem brings the patient to the hospital(preferable quote the patient), and duration[Writing a history & physical]e.g. 34-year-old male with advanced AIDS complains of a” bad cough” and fevers over the last 8days.56-year-old male with a history of ulcerative colitis complains of 3 months of worsening back stiffness, 2 weeks of “a sore on my leg”, and 3days of fevers and bloody, painless diarrhea.History of Present illness:full sentences in chronological mannerbe descriptive not analyticincluding the setting, onset of the problem, the manifestation and the treatment.Seven Attributes of A Symptom: location, quality, quantity or severity, timing(onset, duration, frequency), the setting in which they occur, factors that have aggravated or relieved the symptom, associated manifestations.Pertinent positives & pertinent negativesPast Medical HistoryChildhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever(猩红热), polio etc.Adult disease, in four categories:☑Medical, such as: diabetes, hypertension, hepatitis, asthma, and HIV etc.☑Surgical, such as: trauma, operation(date, type);☑Ob/ Gyn:✓Menstruation history(age at menarche, last menstruation period/ age at menopause, menstrual cycle, menstrual period)✓Obstetric history(G_P_, pregnancy、delivery and complications, )✓Sexual function;✓Method of birth control, such as oral contraceptives, condoms, intrauterine ring;☑Psychiatric;Health maintenance☑Immunization(history and recent immunization);☑Screening test, such as tuberculin test, Pap smear, mammogram, stool test for occult blood, cholesterol test etc.Medication: name, dose, route of administration, interval. Note for recent cessation or change;Allergy:List the substance and the reaction. Allergy vs intolerance;NOTE:药物过敏史与烟酒违禁药物使用分开。
关于药物史和过敏史的位置，一共可以出现在两个地方：现病史，药物、过敏史。
关于烟酒违禁药物使用，可以出现在现病史和个人史中。
英文病历中现病史尽量详尽，如果相关，都应该放入现病史中。
Family HistoryList or diagram each immediate relative (age, health, major illness or cause of death).Similar condition among family members;Presence or not: Infectious disease, such as hepatitis, tuberculosis, STD; Complex disease with a hereditary trend, such as HTN, DM, CAD, elevated cholesterol level, stroke, cancer(specify type),arthritis, asthma, headache, seizure, mental illness, allergies etc.Personal and Social History:[written in fragments]Important life experiences in chronological manner: Birth, growth and development, education level(military experience), job history(with or without radiation or toxin contatct), retirement;sexual and Marital history;Source of stress, religious affiliation and spiritual beliefs;Tobacco(pack per year)/alcohol/drug(illicit) abuse:Lifestyle habits:☑Exercise and diet--Food intolerance☑Safety measures such as use of seat belts, bicycle helmets, sunblock etc.☑Activities of daily living(ADLs), especially important in elderly patients.Review of Systems(ROS)NOTE:系统回顾中描述的是近期出现或尚处于活动期的疾病或症状，而非很久以前发生的。
它的目的是尽量详尽和全面，避免漏掉与现病不相关而忽视的症状、疾病。
本部分明确的任何问题，都需要在小结和诊疗计划中作进一步的阐述。
在ROS中明确的问题，与现病相关的应放在现病史，既往重大健康事件应放在既往史。
General: Usual weight, recent weight change. Weakness, fatigue, or fever.Skin: dryness or sweating; changes in color; (regional)Rashes, lumps(肿块), sores, itching; changes in size or color of moles(痣); changes in hair or nails;Head, Eyes, Ears, Nose, Throat (HEENT):Head: Headache, dizziness, lightheadedness, head injuryEyes: Visual acuity(视力, glasses or contact lenses, last examination) , visual fields[spots(点), specks(斑)], double or blurred vision, flashing lights, pain, redness, excessive tearing; history of glaucoma, cataracts; Ears: hearing(excellent or impaired, hearing aids ?), tinnitus(耳鸣), vertigo(眩晕), earaches(耳痛), infection, discharge;Nose and sinuses:; nasal stuffiness(不通气), discharge, or itching, nosebleeds; Frequent colds, hay fever; sinus trouble(tenderness);Throat (or mouth and pharynx): gums( bleeding gums);teeth[dentures(牙托), if any, and how they fit], last dental examination; sore tongue; dry mouth; frequent sore throats; hoarseness(声嘶);Neck: lumps; pain, or stiffness in the neck; goiter;Breasts: Lumps, pain, or discomfort; nipple discharge; self-examination practices;Respiratory: Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing. Last chest x-ray. History of asthma, bronchitis, emphysema, pneumonia, and tuberculosis, pleurisy.Cardiovascular: palpitations,chest pain or discomfort, dyspnea, cyanosis, orthopnea(端坐呼吸), paroxysmal nocturnal dyspnea(夜间阵发性呼吸困难),lower extremities edema, syncope. Positive results of past electrocardiograms or other cardiovascular tests. History of high blood pressure, rheumatic fever, heart murmurs;Gastrointestinal: anorexia (loss of appetite), trouble swallowing, heartburn, excessive belching(嗳气), nausea, vomiting, hematemesis, Abdominal pain/distension, bloating(胀气), diarrhea, constipation, change of bowel movements, stool color[ black or tarry stools(柏油样便)] and size, change in bowel habits, pain with defecation, rectal bleeding , hemorrhoids. Jaundice, itching.Urinary: Frequency and urgency of urination, odynuria, incontinence or dysuria(排尿困难)[ in males, reduced caliber or force of the urinary stream, hesitancy, dribbling(细流)], kidney or flank pain, hematuria, pyuria(脓尿), chyluria(乳糜尿), polyuria or oliguria, anuria, nocturia(夜尿增多). History of kidney stones, urinary infections, ureteral colic(输尿管绞痛), suprapubic pain.Genital:Male:☑Hernias. Discharge from or sores on the penis; testicular pain or masses; scrotal pain or swelling.☑Sexual preference, interest, function, satisfaction, birth control methods(condom use), and problems.☑History of sexually transmitted diseases, exposure to HIV infection and their treatments.Female:☑Vaginal discharge, itching, sores, lumps.☑Age at menarche; regularity, frequency, and duration of periods; amount of bleeding; bleeding between periods or after intercourse; last menstrual period; dysmenorrhea(痛经); premenstrualtension. Age at menopause, menopausal symptoms, postmenopausal bleeding. [If the patient wasborn before 1971, exposure to diethylstilbestrol (DES)(己烯雌酚) from maternal use duringpregnancy (linked to cervical carcinoma)].☑Sexual preference, interest, function, satisfaction, birth control methods, any problems, including dyspareunia(交媾困难).☑Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy.☑History of sexually transmitted diseases, exposure to HIV infection and their treatments. Peripheral vascular: Intermittent claudication, leg cramps; varicose veins, past clots in the veins; swelling in calves(腓肠), legs, or feet; regional swelling with redness or tenderness; color change in fingertips or toes during cold weather.Musculoskeletal: Muscle or joint redness, swelling, pain, stiffness, weakness, or limitation of motion or activity. If present, describe location of affected joints or muscles, timing of symptoms (e.g. morning or evening), duration. History of trauma, arthritis, gout. Presence of muscle atrophy, joint/vertebral deformity. Psychiatric: mood disorder(depression, anxiety, nervousness, tension, elation); disorientation, delirium, hallucination; history of psychiatric disorder, suicide attempts, if relevant.Neurologic: Changes in mood, speech; changes in orientation, attention, memory, insight, or judgment; headache, dizziness(头晕), fainting(晕厥), vertigo(眩晕), blackouts(一过性黑矇), weakness; seizures; paralysis and muscular atrophy; numbness or loss of sensation, tingling(麻刺感) or “pins andneedles”[hyperesthesia(过敏), dysesthesia(倒错), hyperpathia(过度), paresthesia(异常)]; tremors or other involuntary movements.Hematologic: Anemia(pallor, dizziness, fatigue), easy bruising or bleeding, past transfusions and transfusion reactions.Endocrine: developmental malformations, build(obese, or thin), stature(tall or short); excessive thirst or hunger, heat or cold intolerance, excessive sweating, tremor, polydipsia(多饮), polyphagia(多食), polyuria; (hyper-hypo) pigmentation, abnormal hair distribution.PHYSICAL EXAMINATION [fragments]General survey:the patient’s general state of health(cachectic, good), any sign of distress(cardiac/pulmonary, pain, anxiety or depression), height, weight, build, and sexual development;the patie nt’s facial expressions and manner, and reactions to persons and things in the environment; the patient’s manner of speaking and note the state of awareness or level of consciousness;Note posture(orthopnea), motor activity, and gait;dress, grooming(修饰), and personal hygiene; any odors of the body or breath(alcohol or fruity odor). Vital Signs: BP(standing or supine, left or right arm), HR and Rhythm(regular or arrhythmic), RR, Temperature(oral or axilla). Ht(Height), Wt(weight), calculated BMI.Skin: color(normal, increased or loss of pigmentation, pallor, redness, cyanosis, yellowing);moisture(dryness, sweating, oiliness); temperature(generalized & regional-red areas), texture(roughness and smoothness), flexibility, lesions[macule( 斑), papule(丘疹), vesicle(水泡), nevus(mole痣), 7 attributes], pressure sores, crepitus(捻发音); change in hair(quantity, distribution and texture) or nails(color, shape, lesions);HEENT(Head, eye, ear, nose, throat):Head: hair(quantity, distribution, texture, pattern of loss, if any); scalp[scaliness(多鳞屑), lumps, nevus etc.]; skull(size, contour, deformity, depression, lumps, tenderness); face( skin, facial expression, asymmetry, involuntary movements, edema and masses);Eye: visual acuity[myopia(近视), presbyopia(远视)]; visual fields(hemianopsia, blind spot); position and alignment of the eyes[exophthalmos, enophthalmos(眼球下陷)], eyebrow(quantity, distribution), eyelids[width of palpebral fissure(睑裂宽度), edema, color, lesion, condition and direction of the eyelashes, adequacy with which the eyelids close esp prominent eyes, facial paralysis, unconsciousness];lacrimal apparatus and nasolacrimal duct(swelling, excessive tearing or dryness); conjunctiva(bulbar, palpebral) and sclera(color, vasculature, nodules, swelling); cornea and lens[cornea reflection, opacity(混浊)];Iris(crescent shadow—open or close-angle glaucoma); pupils[size(large>5mm, smaller<3mm), shape, symmetry (anisocoria瞳孔不均), pupillary reaction to light(the direct reaction, the consensual reaction, near reaction-convergence & accommodation)]; extraocular muscle[conjugate movement in 6 directions, convergence, nystagmus(眼震), lid lag-hyperthyroidism];Ear: auditory acuity; air and bone conduction(sensorineural & conductive hearing loss); auricle(外耳廓)(size, symmetry, location, deformity, pain, gout); external auditory canal(yellowish, pus, blood or CSF discharge; for patient with tinnitus, check the presence of cerumen or foreign body occlusion, constriction); eardrum(perforation); mastoid(tenderness);Nose: contour(deformity, asymmetry, saddle nose); ala nasi[nasal ale flap()]; septum(deviation, inflammation, perforation, epistaxis鼻衄);turbinate[鼻甲]; nasal cavity (obstruction, ulcers and polyps)and mucosa(color, swelling, bleeding, clear or purulent discharge); nasal sinus(frontal sinus, maxillary sinus, ethmoidal sinus-tenderness);Throat (or mouth and pharynx):lips[color, moisture, lesions(lumps, ulcers, cracking, scaliness)]; oral mucosa[color, ulcers(aphthous ulcer鹅口疮), white patches, nodules]; gums[color and ulceration] and teeth; the roof of the mouth(color and architecture of the hard palate); the tongue[color; texture(质地)- smooth tongue, beefy tongue, strawberry tongue, fissured tongue, geographic tongue;movement-asymmetrical protrusion; ulceration; nodules] and floor of mouth; the pharynx[soft palate, anterior and posterior pillar, uvula, tonsils—color, symmetry, swelling, exudate, ulceration, tonsillar enlargement]; larynx(hoarseness, mute); odor(alcohol, fruity, garlic)Parotid gland: enlargement, tenderness, redness;Neck:carotid artery(prominent pulsation, murmur) and jugular vein(distension); trachea[midline position/deviation]; thyroid gland[size -goiter, shape, nodule, consistency; arterial thrill, murmur]; limitation of motion, rigidity & stiffness; lumps, tenderness;Lymphy nodes: preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical(posterior cervical, deep cervical chain), supraclavicular, axilla, epitrochlear, inguinal lymph nodes(number, size, shape, delimitation界定-discrete or matted together, mobility, consistency硬度, tenderness );Thorax & lungsThorax：respiratory movement[manner, rate, rhythm, depth, effort of breathing-respiratory difficulty(cyanosis; wheezing, stridor; three concave sign)]; chest wall(symmetry, lesion, crepitus, edema);Pulmonary:☑Inspection: abnormal retraction of lower interspaces during inspiration, local lag or impairment in respiratory movement;☑Palpation: chest expansion(symmetry), tactile fremitus(absent or decreased), pleural friction fremitus;☑Percussion: resonance, hyperresonance & dullness;☑Auscultation:★breath sound(vesicular, bronchovesicular, bronchial)-pitch, intensity, duration of expiratory and inspiratory sounds.★Adventitious sound—crakles(爆裂音)(rales湿罗音), rhonchi(干罗音), wheezes(喘鸣);★Transmitted voice sound★Pleural friction rubCardiovascularJugular venous pressure(JVP-centimeters above sternal angle) and pulsation(amplitude and timing);Carotid pulse: amplitude[small, thready丝, weak; bounding; pulsus alternans, bigeminal pulse(二连脉), paradoxical pulse(奇脉)], contour(speed of upstroke, duration of summit, speed of downstroke) and presence or absence of bruits or thrills;Heart：☑Inspection(tangential切线视诊): point of apical impulse(point of maximal impulse-PMI)☑Palpation: thrills, pericardial friction, PMI(location, diameter, amplitude, duration)NOTES: palpation has replaced percussion in the estimation of cardiac size in most cases, except when apical pulse is not felt.☑☑Auscultation: heart sound, heart murmur[timing–midsystolic, pansystolic, late systolic murmur;shape-crescendo, decrescendo, crescendo-decrescendo, plateau; location; radiation or transmission;quality(blowing, harsh粗糙, rumbling隆隆样, musical);intensity; pitch(high, medium, low)];E.g. th with radiation to the apex [aortic regurgitation]Breasts:size, symmetry, contour[pendulous(下垂); lesions; masses(location, size, shape, consistency,delimitation, tenderness, mobility)], consistency, pain/tenderness, nipple [size, shape, direction in which they point, lesion(rash or ulceration), discharge];AbdomenInspection:☑skin[scar, striae(old silver or pink-purple striae), dilated veins, rashes and lesions]☑the umbilicus(contour-hernia, location)☑the contour of abdomen[flat, rounded, protuberant(膨隆), scaphoid(舟状), markedly concave, flank bulge or local bulge(全腹或局部膨出), peristalsis(蠕动), pulsation(aortic)];Auscultation:☑Bowel sounds: character[normal components-clicks & gurgles; Borborygmus(腹鸣)] and frequency(4-5 per minute);☑Bruits(杂音) over aorta, renal arteries, iliac arteries, femoral arteries;☑Friction rubs over spleen or liver;☑Succusion splash(振水音)Percussion:☑Distribution of tympany or dullness☑Vertical span of liver Dullness in the right midclavicular(6-12cm), midsternal(4-8cm) line; spleen, tympany over gastric air bubble (traube semilunar space)☑shifting dullness☑liver, kidney tendernessPalpation:☑Light palpation, Deep palpation for pain, mass(size, shape, location, consistency, tenderness, pulsation, mobility with respiration, or with examining hand); peritoneal irritation sign(tenderness, rebound tenderness, muscle spasm);☑Liver palpation: lower margin(soft, sharp, regular; bluntness, rounding); texture(tender; firmness, hardness); contour(smooth; irregular); gallbladder(size, shape, tenderness, consistency, Murphy’s sign);☑spleen palpation: size, margin, consistency, contour, tenderness;☑kidney palpation: size, consistency, contour, tenderness. Bladder;☑fluid wave(液波震颤)Genitalia:Male:penis[skin, prepuce(smegma包皮垢), glans(lesions-scars, ulcers, nodules, sign of inflammation), urethral meatus(opening position, discharge), tenderness]; scrotum(skin, contour, swelling-translumination, lumps, veins) and its contents(size, shape- nodule, consistency, tenderness); hernia(type);Female: (lithotomy position, with vaginal speculum of proper size, water soluable lubricant etc.)Assess the sexual maturity of an adolescent patient;HerniaExternal examination: mons pubis(阴阜), labia majora, perineum, labia minora, clitoris, urethral meatus, vaginal introitus(阴道开口)[lesions-inflammation sign, ulceration, swelling(check Bartholin’s gland), nodules; discharge];Internal examination: vaginal mucosa(color, lesion-bulges, ulcer, discharge), cervix(color; position;lesion-ulcerations, nodules, masses, bleeding, discharge; mobility, consistency, tenderness), uterus(bimanual-position, size, shape, consistency, mobility, tenderness, masses), ovaries(size, shape, consistency, mobility, tenderness, masses), pelvic muscles(strength), rectovaginal wall;Rectal: sacrococcygeal and perianal areas(lesion-lumps, ulcers, sign of inflammation, rashes, excoriation表皮脱落; tenderness); anus and rectum(sphincter tone-laxity; tenderness; irregularities-induration 硬结); posterior surface of prostate(size, shape, consistency, lesion-nodule, tenderness);Peripheral vascular system(Arms & Legs): pulse(amplitude & symmetry)(brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial), venous pattern(enlargement or varicosity)Extremities & MusculoskeletalExtremities: The temporomandibular joint(TMJ), shoulder, elbow, wrist and hand, hip, knee and lower leg, the ankle and foot;Spine: scoliosis(侧凸), kyphosis(后凸); the Wright-Schober test(ankylosis);Inspection & Palpation[joint deformity or malalignment(排列错乱), sign of inflammation(swelling, warmth, tenderness, redness); surrounding tissue(skin & muscle -atrophy); audible or palpable crunching during movement of tendons or ligaments]Range of motion and maneuver—extension/flexion, adduction/abduction, internal /external rotation (pronation/supination)[limitation in range of motion, increase mobility, ligamentous laxity(韧带松弛)] Neurologic(资料中没有详细专科查体，根据中文书写要求整理)mental status:☑appearance [level of consciousness(alert, awake)] and behavior, mood[euphoria(精神愉悦)-elated;, apathy(情感淡漠)-remote, indifferent; intense, depressed, anxious, angry, suspicious, evasive] ☑speech and language[quantity-talkative or silent, rate-fast or slow, loudness-loud or soft, articulation of words-clear or obscure, fluency]testing for aphasia, dysphasiaword comprehension, reading comprehension, repetition, writing, naming;☑thoughts and perception★thought process[circumstantiality(), derailment(), flight of ideas(思维奔逸), neologisms, incoherence(不连贯), blocking(思维中断), confabulation(虚构), perseveration(机械重复),echolalia(模仿言语), clanging(声音代词语) ]★thought content[compulsions(强迫重复), obsessions, phobias, anxieties, feelings of unreality, feelings of depersonalization(人格解体), delusion(妄想-delusion of persecution被害妄想)] ★perception(感知觉)-illusion(错觉), hallucination(幻觉)★insight(洞察自知力) and judgment☑cognitive function★orientation(time, place & person)★attention(digit span-normally 5 forward, 4 backward; serial 7s(normally within 1.5min with fewer than 4 errors); spelling backward)★memory(remote, recent memory);★new learning ability(give contents, check 3-5min later)☑higher cognitive function★information and vocabulary(casual talk)★calculating ability★abstract thinking[proverb(格言), similarity]★constructional ability(copy figure of increasing complexity, such as triangle, clock face—rating poor, fair, good, excellent)cranial nerves☑I-Olfactory: sense of smell(loss of smell)☑II-Optic: visual acuity, visual field[confrontation对诊法-homonymous hemianopsia(同侧偏盲)], optic fundi(optic atrophy, papilledema) by ophthalmoscope;☑III, IV, VI-oculomotor, trochlear, abducens: pupil(size, shape, symmetry, pupillary reaction to light, near reaction), extraocular movement[loss of conjugate movement in 6 direction, convergence, nystagmus(plane -vertical, horizontal, rotary or mixed; direction of quick or slow movement; noting the direction of gaze in which it appears), ptosis, width of palpebral fissure;☑V-trigeminal: motor(temporal & masseter muscle-strength & contraction), sensory(pain sensation, temperature sensation, light touch), corneal reflex(use of contact lens ↓),☑VII-facial: general(asymmetry, tics, other abnormal movement), note weakness or asymmetry in facial movements[raise both eyebrows, frown, close both eyes forcefully, show both upper and lower teeth, smile, puff out both cheeks(鼓腮)];☑VIII-acoustic: hearing acuity, air & bone conduction, vestibular function(generally not tested);☑IX, X-Glossopharyngeal & Vagus: voice[hoarse, with a nasal quality(带鼻音)]; bulbar(difficulty swallowing, articulation-dysphonia); movement of soft palate, anterior and posterior pillar, uvula;gag reflex[ (咽反射)-unilateral absence or symmetrically diminished/absent]☑XI-spinal accessory: trapezius, sternocleidomastoid muscle [strength, contraction, atrophy, fasciculation(束颤)]☑XII-hypoglossal: articulation(V,VII, X, XII), tongue(atrophy, fasciculation, asymmetry)motor system☑body position [body position-active(自主), passive, compulsive( forced supine, compulsion prone, compulsion lateral, orthopnea, compulsive squatting(强迫蹲),forced standing, alternative(辗转体位), opisthotonos(角弓反张)]☑involuntary movement[tremor(resting tremor, postural, intention tremor), oral-facial dyskinesia(运动障碍), tics, chorea, athetosis(手足徐动症), dystonia(张力障碍)-spasmodic torticollis(痉挛性斜颈)]☑characteristic of muscle★bulk-size & contour★tone: increased or decreased resistance, marked floppiness, flaccid, lead-pipe rigidity, spasticity;Extremities:Test Flexion(C5/6-biceps) and extension(C6/7/8-triceps) at the elbow; test extension at the wrist(C6/7/8-radial); test grip(C7/8,T1); test finger abduction(C8,T1-ulnar); test opposition of the thumb(C8,T1-median);Test flexion (L2/3/4-iliopsoas), extension(S1-gluteus maximus), adduction (L2/3/4-addcutors), abduction(L4/5, S1-gluteus medius and minimus) at the hips; test extension(L2/3/4-quadriceps), flexion(L4/5, S1/2-hamstrings) at the knee; test dorsiflexion(L4/5) and plantar flexion(S1) at the ankle;Trunk:Flexion, extension, lateral bending of the spine, and thoracic expansion and diaphragmatic excursion(横隔移动) during respiration;☑coordination(共济运动):[four essential elements: sensory sys-position sense; cerebellar-rhythmic movement and steady posture; vestibular sys-balance and coordinating eye, head and body movements; motor sys-muscle strength]★rapid alternating movements(RAM)(轮替实验)(speed-slow, rhythm-irregular, smoothness-clumsy, awkward)★point-to-point movements (finger to nose—指鼻实验; heel to shin—跟膝胫试验)( speed, force, direction, accuracy, smoothness-clumsy, unsteady, inappropriately varying in speed,force, direction)—dysmetria(辩距不良), intention tremor★gait and other related movements[spastic hemiparesis(痉挛性偏瘫), scissors(剪刀), steppage(跨阈步态), ataxic gait(cerebellar, sensory, vestibular), parkinsonian-festinatinggait(慌张), gait of old age, myopathic gait, intermittent claudication]★the Romberg test(for position sense)★test for pronator drift(for muscular strength, coordination, position sense)(轻瘫实验)sensory system☑superficial sensation: pain(pinprick) & temperature[spinothalamic tracts], light touch[both]☑deep sensation[posterior columns]: movement, vibration, position;☑complex sensation[discriminative sensation(辨别性感觉)]: stereognosis(实体觉), number identification, two-point discrimination(两点辨别觉), point localization(定位觉), extinction;☑plantar response(L5, S1), the anal reflex.☑deep tendon reflex(proprioceptive): the biceps reflex(C5/6), the triceps reflex(C6/7), the supinator or brachioradialis reflex(C5/6), the knee(patellar) reflex(L2/3/4), the ankle(archilles) reflex(S1), ☑if reflexes are hyperactive, test for ankle clonus;☑pathological reflex: Hoffman sign, Rossolimo sign, palmomental reflex. Babinski sign and its equivalent (Oppenheim sign, Gordon, Schaefer, Chaddock, Pussep, Gonda)meningeal signs:☑neck mobility: pain and resistence☑Brudzinski’s sign: neck flexion→hips, knees flexion☑Kernig’s sign:☑Lasquet’s signAutonomic nerve function: Skin scratch testLABORATORIES AND IMAGING STUDIESPrinciple: Basic labs first: unusual tests follow; basic radiographic studies; electrocardiogram;Electrolyte panel, chem-7, complete blood count(CBC), liver function test(LFTs), coagulation studies;Urine test[urinalysis(UA)];Chest X-ray(CXR)IMPRESSION(入院诊断)ASSESSMENTPrinciple: Analytic, differential diagnosis presenting personal clinical thinking in full sentences;[REF 1]E.g. So in summary, the patient is a 46-year-old male with a long history of difficult-to-control Crohn’s disease who presents with complaints of 3 days of fever, abdominal bloating and pain, and frequent bloody stools after tapering(逐渐减少) down his mesalamine(5-氨基水杨酸) dose. His exam revealed a mild fever, mild-moderate dehydration[orthostatic hypotension, dry mouth, flat jugular veins, contraction alkalosis(脱水性碱中毒), and prerenal azotemia], moderate right-sided abdominal tenderness with voluntary guarding, and occult blood-positive stools. His labs show an elevated white blood cell count and mild anemia. Notably, this presentation is similar to his prior Crohn’s flare, and it seems most likely that this is a recurrence due to recent tapering of his maintenance medicine.Other possibilities include: infectious diarrhea(the patient’s recent vacation in Mexico puts him at risk for agents like E.coli and Salmonella), appendicitis(with a trio of fever, elevated white blood count, and right lower quadrant pain), and incarcerated(箝闭) inguinal hernia(? Small sliding hernia noted on exam-easily reduced).Less likely concerns would be: nephrolithiasis(the pain was not colicky and the UA shows no blood, but Crohn’s patients are at increased risk for oxalate(草酸) stones due to augmented GI uptake of oxalate form abnormal calcium absorption), pancreatitis(the patient denies significant ethanol consumption, and gallstone-related disease is unlikely as he is status post cholecystectomy, also, blood in stool generally is not seen with pancreatitis), and herpes zoster(带状疱疹)( it is possible to have zoster without rash, but the distribution of the pain is not strictly dermatomal)PLAN (prescription and patient instruction)Principle: enumerate your thoughts; keep it short and to the point; some topics not addressed in assessment section require a brief statement of the problem.3 format:[fragments will do]A specific Problem List[most common]An organ system list done in a set order[address every organ system, best suited for complex patient]And organ system list ordered by relative importance[REF 1]E.g. problem list format:。
