呼吸科英文病例范文寫(xiě)作
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呼吸科英文病例范文1
Medical Record of Admission
Name: Guo XX Sex: Male
Age: 41 years old Marital status: Married Race: Han Occupation: Worker
Place of birth: Chenzhou City, Hunan province
Address: Linwu County, Chenzhou City, Hunan province
Date of admission: 11：12 AM, 05,12,2014 Date of records: 17:20PM, 05,12,2014
Complainer: Guo XX
Chief complaint: Cough for two months, and tachypnea and chest pain for one month.
History of present illness: The patient have no obvious cause cough in
October this year, a small amount of white sticky sputum, blood in the sputum, no 10th, the patients with fever, the highest temperature of 39.2 degrees, tachypnea, chest pain, hence clinic in Linwu county people's hospital, the number of WBC has been checked a little bit high, chest CT shows on the left side of the massive pleural effusion, a little right lung infection, diagnosis "left pleural effusion, pleurisy" to fight infection (specific drug use is unknown), no significant improvement in symptoms. Then transferred to the first people's hospital of Chenzhou, also the number of WBC has been checked a little bit high, calcitonin original high, c - reactive protein and blood sedimentation increase fast, pleural effusion as exudates, diagnosed as "check the left pleural effusion due to: tuberculosis likely, double lung infection", to the amp south + levofloxacin anti-infection, fever back slightly, but still has a low thermal afternoon, in the 2014-11-20 to diagnostic anti-tuberculosis (quadruple the chemotherapy plan: isoniazid 0.3 qd + rifampicin 0.45 g qd + pyrazinamide 0.5 tid + ethambutol 0.75 qd), patient with no fever, cough, chest pain, were compared with the previous improved patient for diagnosis hence to our hospital. Since the onset of the patient with a good spirit, appetite, sleep, and fever, occasionally cough, blood in phlegm, the feces and urine are both normal, regular anti-tb drugs, weight did not
significantly reduce.
Past history: Ever healthy. Denied the history of "hypertension" and "coronary heart disease", "diabetes". Deny "hepatitis b" "TB" "typhoid fever and other infectious disease and exposure history, deny the history of trauma, surgery and blood transfusion, denied drugs and food allergy, history of vaccination is unknown. Systematic review:
Head and facial: No history of visual impairment, deafness, tinnitus, dizziness, nose bleeding, toothache, bleeding gums and voice hoarse. Respiratory system: History of cough, expectoration, hemoptysis, difficulty breathing, tachypnea, fever, chest pain, night sweats.
Circulatory system: History of tachypnea, no palpitation, lower limb edema, the area before the heart pain, blood pressure, syncope.
Alimentary system: No history of belching, acid regurgitation, difficulty swallowing, abdominal distension, abdominal pain, diarrhea, vomiting, jaundice, hem atemesis and melena.
Genitourinary system: No history of urinary frequency, urgency, urine pain, waist pain, hematuria, dysuria, abnormality of urine, facial edema, genital ulcers. Endocrine system and metabolic: No history of fearless cold, afraid of hot, sweaty, fatigue, headache, palpitations, abnormal appetite, polydipsia, polyuria, edema, obesity.
Hematopoietic system: No history of pale skin, dizziness, vertigo, bleeder petechial skin, lymph nodes, liver and spleen enlargement, bone pain.
Neural system: No history of headache, dizziness, memory loss, skin feel abnormal sense or history of convulsions, the language barrier, disturbance of consciousness. Kinetic system: No history of joint pain, trembling, convulsions, paralysis,
paraesthesia.
Mental state: No history of hallucinations, delusions, disorientation, mood disorders. Personal history: Born in origin, not to foreign residents, denied "schistosomiasis epidemic" water and exposure to toxins, denial of serious trauma history and history of play, there are 4 years of exposure to dust, not smoking, not drinking alcohol.
Marital history: Married at 33, have a son and a daughter, spouse and children both healthy.
Family history: There was no similar or specific medical history in his families. Physical examination: T 37.8℃, P 107/min, R 20/min, BP 120/70mmHg. He is well developed and moderately nourished. Active position. His consciousness was clear. the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. The superficial lymph nodes were not found enlarged. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent. No tenderness in mastoid area. Pharynx was not congestive. Tonsils were not enlarged. The neck was soft, jugular veins were not visible and the pulsation of carotid arteries were normal. Thyroid was not enlarged. Trachea was in midline. Chest veins could not be seen easily. No
subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thoracic symmetry on both sides. The tactile fremitus of right lung is
normal, right lung percussion sounds were clear, right lung was clear breathing sound. No rhonchus. No moist rales. The tactile fremitus of left lung is reduced, the respiratory movement degrees. No pleural friction fremitus.
The left lung percussion were solid sounds and The left lung respiration disappeared. No bulge in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line. No thrills and pericardial friction sound.
Border of the heart was normal. Heart rate 107/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen was flat and soft. No abdominal wall varicosis. Gastrointestinal type or peristalses were not seen. No tenderness or rebound tenderness in the abdomen.Liver and spleen was untouched. No masses. Shifting dullness negative. Fluid thrill negative. No pain in renal regions when percussion. Borborygmus was normal, 4/min. No vascular murmurs. Genitourinary system and rectum were not examined. No articular swelling. Free movements of all limbs. The muscular strength tension of limbs were normal. No edema. Physiological reflexes were existent without any pathological ones.
Auxiliary examination:
Diagnosis: Check the left lesion and pleural effusion
Tuberculosis likely
Tumor wait for exclusion
Physician sign: Zhang Lian
呼吸科英文病例范文2
Medical Records for Admisson
General information
Name: Du xuechun
Age: 52
Sex: Male
Race: Han
Nationality: China
Address: Room.479, Building.11, Occupation: manager Marital status: Married Date of admission: Dec 17th, 2014, 16:00 Date of record: Dec 18th, 2014, 15:32 Complainer of history: Du xuechun
Reliability: Reliable Station north Road, Changsha, Hunan.
Chief complaint: Cough and expectoration for one month, and shortness of breath after the event for half a month.
Present illness:
The patient felt itchy throat and coughed in mid-November 2014 after catching a cold. It is a paroxysmal cough relieved at night and occurred repeatedly in a moderate degree usually with white frothy sputum easily coughed. He didn’t have fever, chest tightness and pain and shortness of breath. After taking medicine from Chinese medicine practitioners, he felt shortness of breath especially when he went upstairs and walked fast. Other symptoms still existed. On Dec 13th, 2014, the patient came to our outpatient and was diagnosed “lung infection with tuberculosis”. During Dec 14th to Dec 16th, 2014, the patient went to Chest Hospital of Hunan province and was diagnosed fungal infections and Alveolar proteinosis. Now to seek further therapy the patient was accepted to our department because of “unknown of lung disease”.
Since onset, her appetite was good, and both her spiritedness and physical energy are good. Defecation and urination are normal. Past history
The patient is healthy before.
No history of operative diseases. No history of infective diseases. No
allergy history of food and drugs.
System review
Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain.
Alimentary 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 system: No history of headache or dizziness.
Personal history
He was born in Hunan and almost always lived there. His living conditions were good. No bad personal habits and customs. Quitting smoking 10 years and have regular life.
Obstetrical history: He married at 26, had a daughter. His daughter and wife are healthy.
Family history: No similar family history and special medical history.
Physical examination
T 36.7℃, P 96/min, R 18/min, BP 140/108mmHg. He is well developed and moderately nourished. Active position. His consciousness was clear. His face was cadaverous and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.
Head
Cranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory 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 nares flaring. No tenderness in nasal sinuses.
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary 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 midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformities.
Breast: Symmetric bilaterally.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 18/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. Breath sound is rough. 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 impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 96/min. Cardiac rhythm was regular. No pathological murmurs.
Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There 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 murmurs.
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 examed
Investigation
Xiangya hospital (Dec 13th, 2014)
Blood-Rt: WBC 9.9×109/L, N 32.3%, L 53%, RBC 4.85×1012/L, Hb 153g/L, PLT 144×109/L.
Hepatitis B three pairs: HBsAg, HBeAg and HBcAb were positive, and others were negative.
History summary
1. Patient was male, 52 years old
2. Cough and expectoration for one month, and shortness of breath after the event for half a month.
3. No special past history.
4. Physical examination: T 36.7℃, P 96/min, R 18/min, BP 140/108mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Breath sound is rough. No other positive signs.
5. investigation information:
Xiangya hospital (Dec 13th, 2014)
Blood-Rt: WBC 9.9×109/L, N 32.3%, L 53%, RBC 4.85×1012/L, Hb 153g/L, PLT 144×109/L.
Hepatitis B three pairs: HBsAg, HBeAg and HBcAb were positive, and others were negative.
Impression: Unknown of diffuse lung disease Alveolar proteinosis with infection?
Fungal infections?
Chronic viral hepatitis
Hypertension grade1 in high-risk
group
Signature: He Lin (05-10033)
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