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英文大病例写作示例(三)

RS呼吸系统
Trachea central 气管居中。
Respiratory rate15/ min, no respiratory distress呼吸频率15次/分,无呼吸窘迫。
Expansion symmetrical and normal胸廓扩张对称正常。
Vocal fremitus normal 语音震颤正常。
Percussion note normal叩击音正常。
Breath sounds vesicular throughout, no added sounds全肺闻及水泡音,无额外音。
Abdomen腹部
No scars/ veins distension无疤痕、静脉怒张。
Palpation: soft, but tender LIF(left iliac fossa)扪诊:腹部柔软,但有触痛(左髂前窝)。
Percussion note normal叩击音正常。
Auscultation: bowel sounds normal听诊:肠鸣音正常。
Genitalia not examined生殖器未检查。
Rectal examination: not performed肛门检查:未检查。
 
NS神经系统
Higher function normal高级神经功能正常。
Cranial nerves颅神经
ⅰ: normal第一对颅神经:正常。
ⅱ:PERRLA(pupils equal in reaction to light and accomodation)/ normal fundi and visual fields 第二对颅神经:瞳孔对光调节反应等大,正常眼底与视野。
ⅲ,ⅳ,Ⅵ: no diplopia / nystagmus第三、四、九颅神经:无复视和眼球震颤。
ⅴ-Ⅻ: normal第五至十二对颅神经正常。
upper and lower limbs: power, tone, coordination, sensation all normal
上下肢:肌力、肌张力、协调、感觉正常。
Reflexes放射
Right右
Left左
Bideps二头肌
++
++
Supinator旋后肌
++
++
Triceps三头肌
++
++
Knee膝盖
++
++
Ankle踝
++
++
Plantar跖
Joints and skin: Normal关节与皮肤:正常。
 
 
Summary
47-year-old male smoker with a family history and previous history of ischaemic heart disease, presents with s 4-month history of increasing exertional chest pain and a 4-hour history of persistent, severe pain at rest, which is unrelieved by GTN and associated with nausea, vomiting, and sweating. On examination, he has a resting tachycardia and evidence of left ventricular dilatation with a displaced apex beat and possible secondary mitral regurgitation. The most likely diagnosis is acute myocardial infarction.
47岁男性,有吸烟史与缺血性心脏病的家族史与过去病史,近4个月胸骨后压痛渐重,今静息时出现持续严重疼痛4小时,硝酸甘油未能缓解,并伴有恶心、呕吐与大汗。体检发现有静息时心动过速与左心室扩大依据,心尖搏动偏移,可能有二尖瓣返流。可能性最大的诊断是急性心肌梗死。
 
Problem list问题总结
1.       chest pain-myocardial infarction?胸痛是否由心肌梗死引起?
2.        known ischaemic heart disease- myocardial infarction, post-infarct angina已知缺血性心脏病是否引起心肌梗死、梗死后心绞痛?
3.       Clinical left ventricular enlargement with secondary mitral regurgitation?
临床上有否左心室扩大伴二尖瓣返流?
4.       Previous duodenal ulcer but quiescent for years-no contraindications to thrombolysis?
十二指肠溃疡但静息多年,对溶栓疗法是否有禁忌症?
5.       Gout – can be precipitated by diuretics prescribed for cardiac failure
痛风――治疗心衰的速尿可促发痛风
6.       HGV driver – should he still be driving?
是否适合继续从事重型货车司机驾驶职业?
 
 
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