英文病历报告作文模板
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英文病历报告作文模板
英文：
Medical Record Report。
Name: John Smith。
Age: 35。
Gender: Male。
Date of Admission: 05/01/2021。
Date of Discharge: 05/07/2021。
Chief Complaint:
The patient complained of a persistent cough and
shortness of breath.
History of Present Illness:
The patient had a persistent cough and shortness of
breath for two weeks. He tried to treat himself with over-the-counter medication but his symptoms did not improve. He
decided to seek medical attention when his cough became
more severe and he started to experience chest pain.
Past Medical History:
The patient has a history of asthma and seasonal
allergies. He has been hospitalized in the past for asthma
exacerbations.
Physical Examination:
On physical examination, the patient had wheezing and
crackles in his lungs. His oxygen saturation was 92% on
room air.
Diagnostic Tests:
A chest X-ray showed bilateral infiltrates consistent
with pneumonia. A COVID-19 test was negative.
Treatment:
The patient was started on antibiotics for pneumonia
and given nebulizer treatments for his asthma exacerbation.
He was also given supplemental oxygen to maintain his
oxygen saturation above 94%.
Outcome:
The patient's symptoms improved with treatment and he
was discharged home after a week in the hospital.
中文：
病历报告。
姓名，约翰·史密斯。
年龄，35岁。
性别，男。
入院日期，2021年5月1日。
出院日期，2021年5月7日。
主诉：
患者抱怨持续咳嗽和呼吸急促。
现病史：
患者已经持续咳嗽和呼吸急促两周了。他试图用非处方药治疗，但症状没有改善。当他的咳嗽变得更加严重并开始出现胸痛时，他决定寻求医疗帮助。
既往病史：
患者有哮喘和季节性过敏的病史。他曾因哮喘急性发作住院治疗。
体格检查：
体格检查显示，患者的肺部有哮鸣音和湿啰音。他的室内氧饱和度为92％。
诊断检查：
胸部X线显示双侧浸润，符合肺炎的诊断。COVID-19检测为阴性。
治疗：
患者开始接受肺炎的抗生素治疗，并接受雾化治疗以治疗哮喘急性发作。他还接受了补充氧气的治疗，以保持室内氧饱和度在94％以上。
结局：
患者的症状在治疗后得到了改善，并在住院一周后出院回家。
