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英文大病例写作示例(一)

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,向颈与双臂放射,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)
 
Relieving/exacerbating factors缓解与恶化因素
GTN(glyceryl trinitrate) provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.(硝酸甘油平时能在数分钟内缓解疼痛,但本次无效,无其它缓解和恶化因素。)
 
Associated symptoms 相关症状
Nausea, vomiting×2, sweating, dizzy(恶心、呕吐2次、出汗、眩晕)
1997:external chest tightness and dyspnea initially controlled atenolol.
1997年:出现胸外疼痛与呼吸困难,最终经服atenolol控制。
4/12 symptoms worse, exercise tolerance 200 yards on flat, limited by chest pain
4月12日,症状加重,受胸痛限制,仅耐受平地行走200码
No rest pain, no orthopnoea, no PND
无静息时疼痛,无端坐呼吸、无阵发性夜间呼吸困难
 
Risk factors危险因素
Hypertension-no高血压:无
Smoking-20 cigarettes per day for 16 years吸烟:16年来每天20支
Diabetes-no糖尿病:无
Cholesterol-never checked胆固醇:未查
Ischemic heart disease-angina, previous MI缺血性心脏病:心绞痛、有心肌梗死病史
 
PMH(past medical history)过去史
1963: appendectomy 1963年:阑尾切除手术
1972: duodenal ulcer, no symptoms since1972年:十二指肠溃疡,之后无症状
1986: myocardial infarction, full recovery / No subsequent investigation1986年:
心肌梗死,完全恢复,无随访
1989: gout quiescent on treatment1989年:痛风治疗期间症状静止
No diabetes, hypertension, rheumatic heart disease, tuberculosis, epilepsy, asthma, jaundice, cerebrovascular disease.无糖尿病、高血压、风湿性心脏病、结核病、癫痫、哮喘、黄疸、脑血管疾病
(待续)