医学题目模板英语作文

医学题目模板英语作文英文回答：
Medical Case History Template。

Patient Information。

Name:
Age:
Sex:
Date of Birth:
Medical Record Number:
Reason for Visit:
History of Present Illness。

Describe the patient's current symptoms in detail, including:
Onset: When did the symptoms begin?
Duration: How long have the symptoms lasted?
Character: Describe the nature of the symptoms, such as pain, discomfort, or functional impairment.
Location: Where are the symptoms located?
Severity: Rate the severity of the symptoms on a scale of 1 to 10.
Palliating and aggravating factors: Identify any factors that make the symptoms better or worse.
Past History。

Medical history: List any previous medical conditions,
surgeries, or hospitalizations.
Surgical history: Describe any previous surgeries, including the date, type of surgery, and any complications.
Immunization history: Record the patient's immunization status for common childhood vaccines.
Allergies: Note any known allergies to medications, food, or environmental substances.
Medications: List all current medications, including the name, dose, frequency, and route of administration.
Family History。

Describe any significant medical conditions or diseases that run in the patient's family.
Social History。

Occupation: Describe the patient's current and
previous occupations.
Education: Record the patient's educational level.
Marital status: Note the patient's current marital status.
Habits: Describe any relevant habits or lifestyle factors, such as smoking, alcohol consumption, or drug use.
Physical Examination。

General: Describe the patient's overall appearance, vital signs, and general health status.
Skin: Examine the skin for any rashes, lesions, or other abnormalities.
Head, Eyes, Ears, Nose, Throat (HEENT): Evaluate the head, eyes, ears, nose, and throat for any abnormalities.
Cardiovascular: Auscultate the heart for murmurs,
gallops, or arrhythmias. Check the pulses for quality and equality.
Respiratory: Listen to the lungs for any abnormal breath sounds. Percuss the chest to detect any dullness or hyperresonance.
Gastrointestinal: Palpate the abdomen for any tenderness, masses, or hepatosplenomegaly.
Genitourinary: Examine the external genitalia and perform a rectal examination if indicated.
Musculoskeletal: Check for any pain, swelling, or deformities in the muscles, bones, or joints.
Neurological: Assess the patient's mental status, cranial nerves, motor function, and sensory function.
Laboratory and Imaging Studies。

List any laboratory tests or imaging studies that have
been ordered or performed.
Include the results of any tests that have been completed.
Assessment。

Provide a differential diagnosis, which lists the most likely potential diagnoses for the patient's symptoms.
Describe the patient's current diagnosis and any additional diagnoses that have been made.
Plan。

Outline the treatment plan for the patient, including:
Medications: Prescribe any necessary medications, including the name, dose, frequency, and route of administration.
Procedures: Describe any procedures that will be
performed, such as biopsies or surgeries.
Discharge instructions: Provide instructions for the patient after discharge, including follow-up appointments and any lifestyle modifications.
中文回答：
医学病历模板。

患者信息。

姓名：
年龄：
性别：
出生日期：
病历号：
就诊原因：
现病史。

详细描述患者当前的症状，包括：
起病，症状开始的时间。

持续时间，症状持续的时间。

性质，描述症状的性质，如疼痛、不适或功能障碍。

部位，症状的发生部位。

严重程度，使用 1 到 10 的等级对症状的严重程度进行评分。

缓解和加重因素，识别使症状改善或恶化的任何因素。

既往史。

病史，列出任何既往的医疗状况、手术或住院记录。

手术史，描述任何既往的手术，包括日期、手术类型和任何并发症。

免疫接种史，记录患者对常见儿童疫苗的免疫状态。

过敏史，注意任何已知的药物、食物或环境物质过敏。

用药史，列出所有当前的药物，包括名称、剂量、频率和给药途径。

家族史。

描述患者家族中出现的任何重大医疗状况或疾病。

社会史。

职业，描述患者当前和以前的职业。

教育，记录患者的教育水平。

婚姻状况，注明患者当前的婚姻状况。

习惯，描述任何相关的习惯或生活方式因素，如吸烟、饮酒或吸毒。

体格检查。

一般情况，描述患者的总体外观、生命体征和总体健康状况。

皮肤，检查皮肤是否有任何皮疹、病变或其他异常。

头、眼、耳、鼻、喉（HEENT），检查头部、眼睛、耳朵、鼻子和喉咙是否有任何异常。

心血管系统，听诊心脏是否有杂音、奔马律或心律失常。

检查脉搏的质量和是否对称。

呼吸系统，听诊肺部是否有任何异常呼吸音。

叩诊胸部以检测任何浊音或过清音。

消化系统，触诊腹部是否有任何压痛、肿块或肝脾肿大。

泌尿生殖系统，检查外部生殖器，并在必要时进行直肠检查。

肌肉骨骼系统，检查肌肉、骨骼或关节是否有任何疼痛、肿胀或畸形。

神经系统，评估患者的精神状态、脑神经、运动功能和感觉功能。

实验室和影像学检查。

列出已订购或已进行的任何实验室检查或影像学检查。

附上已完成的任何检查结果。

评估。

提供鉴别诊断，列出患者症状最可能的潜在诊断。

描述患者的当前诊断和已做出的任何其他诊断。

计划。

概述患者的治疗计划，包括：
用药，开具所有必要的药物，包括名称、剂量、频率和给药途径。

手术，描述将进行的任何手术，如活检或手术。

出院指导，提供患者出院后的指导，包括复诊预约和任何生活方式的调整。