医学英语病历范文

医学英语病历范文
Medical Record
Patient Information:
Name: John Smith
Age: 45
Gender: Male
Date 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]。