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医学英文摘要及病例

医学英文摘要及病例

CASE HISTORY (1)Patient CPR,a salesman of 35,married, was admitted on September 25,1998,complaining of anorexia and pain in RUQ for 5 days,and yellowish discoloration for 3 days. He started with a “flu-like illness” in the afternoon of September 18, 1998, during which he fell chilly, dizzy, and lack of strength, then, he was confined to bed, In the evening, his temperature was 38.6℃. He vomitted once with food previously ingested.On Sept, 19, he did’nt take his breakfast because he had a persistent nausea. He rejected all sorts of greasy food and could only eat a few table- spoonfuls of porridge with some presevered vegetable and ginger.On Sept, 20, he had no sooner vomitted out whatever he took. Meantime, he noticeed abdominal dull aching in RUQ with gaseous distension and flatus, Bowel was moved every 2~3 days with dark brown formed stools.Urine was scanty and highly colored. He was told by his wife that his eyes and skin were yellowish tinged. On Sept, 23, but since then. his appetite improved, nausea and vomiting disappeared and abdominal pain and distension alleviated.No previous history of jaundice, anorexia or general malaise. Never received blood transfusion or percutancous injection. None of the family members intimate friends, or colleagues was known to have Liver disease.Physical Examination T 37℃. P 72/min, R 20/min, BP 15/10Kpa, W.D ﹠W.N. Mentality clear and cooperative. Skin and sclerae moderately jaundiced,A suggestive spider angiome is seen in the left postauricular region. Tongue coated. No general glandular enlargement. Lungs clear. Heart normal.. Liver is palpable about 2cm below costal margin and tender, Spleen is just palpable. No shifting dullness was found. Spine and extremities are normal. Knee jerks are present.Questions: 1.What is the most possible diagnosis?2.How to treat this case?CASE HISTORY (2)Patient CJW, a farmer of 25 years old, unmarried, was admitted on November 13 2001, Complainning of persistent high fever for 20 day and mental dullness for 3 days.He started with low grade fever on October 23, 2001, during which he felt discomfort, malaise, dizzyiness, and myalgia, 5 days later, his tempraturer rised to 39~40℃. He began to feel sever headache, general bodyaching, anorexia, nausea and vomitting. He was treated with some tablet drug , 2. Tablets twice a day for 5 days in local clinic. But had no effect. The high fever persist and accompanied with diarrhea passing loose stool 1~2 times a day. Three days ago, patient had mild non-productive cough but passed dark stool ,then he became unconsiousness and delirium but no convulsion.No previous history of fever except “measles” and “malaria” in childhood. Never received any vaccine innocalation ,had no traveling history before the illness. One month ago. His brother was ill with same disorder but the diagnosis had no confirmed. P.E. T 39℃. P 144/min, R 30/min, BP 112/75mmHg well devlopment but nutrition was poor, unconsciousness. No jaundice,no eruption, and no general glandular enlargment.Pupils equal on both sides and reactive to light. Neck soft. Lungs clear. Techgcardia with normal heart sound abdominal soft and of distention. No tenderness. Liver is 1cm and spleen 3cm below costal margin. Spine and extremities are normal, Knee jerks are present. Kernig’s signs and Brudxinski’s signs negative, no pathological reflexes.Lab. Finding: blood: WBC 4.7×109/L, N 0.75, L 0.25ALT: 60u/LUrine: protien(+)Stool: dark, OB(++)Serological test: HBsAg(+) eAg(+) Anti-HBc(+)Questions: 1. What is the most possible diagnosis? Why?2. How to treat the patient?Medical Record of COPDName:Liang Ya jun Occupation: driverSex:male Date of admission: Jan ,17,2007Age: 70 years old Date of record: Jan,17,2007Nationality: Han Narrator of history: HimselfBirth place: Beijing Level of history: reliableChief complaint: Cough with productive of sputum for 30 years, wheeze for 10 years, and got worse for 3 days.History of present illness: 30 years ago after exposure to cold weather, the patient suffered from a cough, with purulent sputum, without fever、fatigue、night sweats、hemoptysis. With theanti-infection therapy, He was cured. Since then he was often recurrent 2-3 times every year after catching a cold or having pulmonary infection. 20 years ago, he was diagnosed the chronic bronchitis, and he had to be admitted 1-2 times 1 year for the therapy. 10 years ago, he felt shortness of breath, particularly after sports ,and 5 years ago, he began edema in his legs and feet.3 days ago, he felt worse without any reson. He coughed all night, couldn’t lie down during sleep, sometimes with dyspnea. The sputa was sticky and purulent. But no fever. He took the oral ampicillin and aminophylline by himself ,but they didn’t work. Then he came to emergency department of TianTan Hospital. The results of blood routine was: WBC:12500/mm3, N:82.3%. The X-ray of lung: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema. He was given some drugs of anti-infection, but the effect is not good. To be well treated, he was incharged of acute episode of COPD.These days, he felt weakness, poor of appetite, the urine and stool are normal, his weight did not change.Past history:He has had Hypertension for 30 years, DM for 4-5 years . 1986: myocardial infarction, full recovery / No subsequent investigation.Social History: Smoking for 50 years ,the amount is about half a cigarette case per day. Never drink. Born and lives in Beijing, Never been to area of pestilence. Married for 45 years with 2 children and both of them are healthy.Family history: No family history of chronic disease and genetic disease.Review of SystemsRespiratory system: Same as the history of present illness.Gastrointestinal tract: No current indigestion. No vomiting/ dysphagia/ diarrhea/ constipation/ abdominal pain.Cardiovascular system: No current chest pain. No palpitation/loss of consciousness.Genitourinary system: No urinary systems.Nervous System: No headache/ syncope/ vertigo/ balance problem. No dizziness/ limb weakness/ sensory loss. No disturbance of vision/ hearing/ smell/ speech.Musculoskeletal system: No joint pain/ stiffness/ extremity pain/ decreased range of motion. No disability.Allergies History: penicillin-skin rashPhysical examinationT: 37.2℃R: 24bpm P: 101bpm BP: 110/60mmHgGeneral: well. No anemic looking. consciousness is clear. His action is free .Skin: No petechiae, purpura, Anlcteric. No cutaneas Lesions or rashes. His feet is Ⅱdegree edema .Nodes: Surface nodes unpalpable.Eyes: conjunctive normal.No icterus, hemorrhage. Lids without lesions. Pupils equal, round and react to light and accommodation.Neck: Supple, Trachea midline. Thyroid not enlarged and without nodules. Jugular veins flat. Venous pulses normal.Chest: Tubbish chest contour. No catfale, pain.Lungs: Inspection:respiration equal,24bpm,rhythm regular.Palpation:with symmetrical full expansion.No thrills.Percussion:No percussion dullness.Auscultation: coarse. Sometimes there are moist and dry rales in both lungs. There is no sounds of pleural friction.Heart: Inspection: No visible lifts.Palpation:rate:101bpm. Rhythm is regular. No lifts thrills,heaves.Percussion: Heart border normal as follows:Right(cm) Rib Left(cm)2 Ⅱ 22 Ⅲ 4.53 Ⅳ 6Ⅴ8MCL=8cmAuscultation: rate:101bpm,rhythm is irregular, P 2> A 2. No splitting of heart sound.No cardiac murmurs or pericardial sound.Abdomen: Inspection:No scars or visible masses.Venous pattern normal.Palpation: Soft, no pain, mass, thill or fluid wave. Liver and spleen not palpable.Percussion:Liver sonant normal.Auscultation:Bowel sound 3bpm.No bruit.Nerve: Higher function normal.Cranial nervesⅰ-Ⅻ: normal.Upper and lower limbs: power, tone, coordination, sensation all normal.Laboratory and diagnostic testsBlood routing: WBC 12500/mm3, N 82.2%.Arterial blood-gas : PH 7.35 PO2 58mmHg PCO2 70mmHg BE 5mmol/L.X-RAY: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterialtrunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema. Summary70-year-old male smoker with a family history and previous history of chronic bronchitis, presents with 20-year history of cough, sputum, wheeze and got worse for 3-day, which is unrelieved by ampicillin and aminophylline. On examination, there are moist and dry rales in both lungs.Blood routing: WBC 12500/mm3, N 82.2%.X-RAY: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema.The most likely diagnosis is an acute episode of COPD(chronic obstructive pulmonary disease).Diagnosis: Acute episode stage of COPD(chronic obstructive pulmonary disease)Chronic bronchitisObstructive emphysemaChronic pulmonary heart diseaseDecompensation stage of cardiac and lung functionsType 2 respiratory failureCoronary heart diseaseOld myocardial infarctionSinus heart rateHeart border normalCardiac function 2 classicHypertension 3 classic2 type Diabetes mellitusDr. XXA Sample of Complete HistoryPATIENT'S NAME: Mary SwanCHART NUMBER: 660518DATE OF BIRTH:10-5-1993SEX: FemaleDATE OF ADMISSION: 10-12-2000DATE OF DISCHARGE: 10-15-2000Final Discharge SummaryChief Complaint:Coughing, wheezing with difficult respirations.Present Illness:This is the first John Hopkins Hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to Tedral or cough medicine.The wheezing progressed and the child was taken to John Hopkins Hospital Emergency Room where the child was given epinephrine and oxygen. She was sent home. The patient was brought back to the ER three hours later was admitted.Past History:The child was a product of an 8.5-month gestation. The mother had toxemia of pregnancy. Immunizations: All. Feeding: Good. Allergies: Chocolate, dog hair, tomatoes.Family History:The mother is 37, alive and well. The father is 45, alive and well. Two sibs, one brother and one sister, alive and well. The family was not positive for asthma, diabetes, etc.Review of Systems:Negative except for occasional conjunctivitis and asthma.Physical Examination on Admission:The physical examination revealed a well-developed and well-nourished female, age 7, with a pulse of 96, respiratory rate of 42 and temperature of 101.0℉. She wasin a mist tent at the time of examination.Funduscopic examination revealed normal fundi with flat discs. Nose and throat were somewhat injected, particularly the posterior pharynx. The carotids were palpable and equal. Ears were clear. Thyroid not palpable. The examination of the chest revealed bilateral inspiratory and expiratory wheezes. Breath sounds were decreased in the left anterior lung field. The heart was normal. Abdomen was soft and symmetrical, no palpable liver, kidney, or spleen. The bowel sounds were normal. Pelvic: Normal female child. Rectal deferred. Extremities negative.Impression:Bronchial asthma, and pharyngitis.Laboratory Data:The white count on admission was 13,600 with hgb of 13.0. Differential revealed 64 segs and 35 lymphs with 3 Eos. Adequate platelets. Sputum culture and sensitivity revealed Alpha hemolytic streptococcus sensitive to Penicillin. Chest x-ray on admission showed hyperaeration and prominent bronchovascular markings. The child was started on procaine Penicillin 600,000 unites IM q.d in accordance with the culture and sensitivity of the sputum.Hospital Course:The child was given Penicillin IM as stated above. Ten drops of Isuprel were added to the respirator every 2 hours. The patient improved steadily. She took her diet well. She was discharged on 10-15-2000 in good condition.Operation procedure: noneCondition on discharge: ImprovedDiagnosis: Asthma. Pharyngitis. Possible right upper lobs pneumonia.。

英文病历样本

英文病历样本

精品好资料——————学习推荐1 / 1 General informationName Age Sex RaceNationalityAddress OccupationMarital statusDate of admissionDate of recordComplainer of historyReliability: Reliable Chief complaintThe patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing.History of present illnessThe patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, went swimming again. Now the condition is more serious. He has a high fever with 39℃ that is accompanied by shaking chills. He has a bad cough with no -blood sputum. When he takes a deep breath, it even hurts.Past medical historyThe patient is health before.No history of infective disease.No allergy history of food and drugs.No operative history.No disease history in other system.Personal historyHe was born in XXX on XXXX and almost always lives in XXX. His living conditions were good. No bad personal habits and customs.Menstrual history: He is a male patient.Family history: His parents are both alive.Physical examination● General: T P R BP W H. The patient is a well -developed, well -nourished adult male. ● HEENT: PERRL, EMOI, small oral aperture.● Neck: JVP to angle of jaw, 2+ carotid pulses, full range of motion.● Cardiac: RRR, normal S1,S2, distant heart sounds.● Chest wall: No subcutaneous emphysema. No tenderness.● Thorax: Symmetric bilaterally.● Breast: Symmetric bilaterally.● Lungs: Respiratory movement is bilaterally asymmetric with the frequency of 24/min. We can hearcoarse breathingwhen listening to a portion of the chest with a stethoscope. There are moist rales on bilateral inferior lung.● Heart: Border of the heart is normal. Heart sounds are strong and no splitting. Rate 150/min. Nopathological murmurs.● Abdomen: Flat and soft. No abdominal wall varicose. There is no rebound tenderness on abdomen orrenal region. Liver and spleen are untouched.● Skin: No pigmentation. No pitting edema. No skin eruption.● Extremities: No articular swelling. All limbs can free move.● Genitourinary system: Not examed.● Rectum: Not examed.● Neural system: Physiological reflexes are existent without pathological ones.InvestigationChest X -ray: Lamellar shadow can be seen in middle and inferior lobe of right lung. The right lung is seriously infected. The volume of useful lung is reduced because of the collection of fluid around the lung.。

英文病例写作范文阅读带翻译

英文病例写作范文阅读带翻译

英文病例写作范文阅读带翻译病例写作是医生日常的工作,英文的病例该如何写呢,接下来店铺为大家整理英文病例写作范文,希望对你有帮助哦!英文病例写作范文篇一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。

英文病例范文

英文病例范文

英文病例范文(中英文版)English Sample Medical Case:John Doe, a 35-year-old male, presented to the emergency department with a chief complaint of severe abdominal pain. The pain started suddenly two hours prior to his arrival and was described as sharp and radiating to his back. Upon examination, his vital signs were stable, but he appeared pale and diaphoretic. The abdomen was tender to palpation, particularly in the upper right quadrant. Laboratory investigations revealed an elevated white blood cell count and increased liver function tests. A diagnosis of acute cholecystitis was suspected, and an ultrasound was ordered to confirm the presence of gallstones.张三,35岁男性,因剧烈腹痛到急诊科就诊。

疼痛在就诊前两小时突然开始,表现为尖锐并向背部放射。

检查时,他的生命体征稳定,但面色苍白且出汗。

腹部触诊时,尤其右上象限区域明显疼痛。

实验室检查显示白细胞计数升高和肝功能测试异常。

英文病历书写教材英文病历(阑尾炎)

英文病历书写教材英文病历(阑尾炎)

MEDICAL RECORDMr. Tiezheng LiuRegistration 4677841#252, Tai Ping street, Xuan Wu, BeijingDec. 21,20039:00 A.M.CHIEF COMPLAINTThis 14-year-old student has had paroxysmal pain transfer to right lower abdomen for 30 hours.HISTORY OF PRESENT ILLNESSMr. Liu was in his usual normal state of health until 30 hours ago, he felt paroxysmal pain in upper abdomen 30 hours ago. He felt it got more and more severe instead of remission. Step by step, the paroxysmal pain transferred to right lower abdomen. During this time, He didn’t eat or drink anything, and took no medication. Position did not affect the pain. No nausea or vomiting, no diarrhea or febrile. So this morning He came to our out-patient.He’s had no fever, chills. He denies past history of similar episodes. He is unaware of a history of abdominal distention. He has no current or past history of change in bowel habits. He has not tarry or black stools, burning abdominal pain or other “indigestion”, kidney stones, polyuria or hematuria. He has had no cough, shortness of breath, or pleurisy. He has no known heart disease. He denies trauma to her chest, back, or legs. He take no regular medications and specifically denies the use of antacids, aspirin, clofibrate (atromid),or alcohol.PAST MEDICAL HISTORYChildhood illness: No measles, rheumatic fever, scarlet fever.Adult illness: None significant.Trauma: None significant.Surgery: None significant.Allergies: No allergy.Medications: None at present.Travel: Never been to other places in the country.Habits: Has never smoked or drunk. No illicit drugs. Regular diet, 3 meals a day.Immunizations: Does not remember childhood shots other than cowpox vaccine.FAMILY HISTORYHe is the only child in the family. His father and mother are both healthy.SOCIAL HISTORYMr. Liuu is a high school student now. He is in good relationship with his classmates usually.REVIEW OF SYSTEMGeneral: see HPI. No weight change.Head: No headache. No dizziness.Eyes: No blurring, double vision, pain, discharge.Ears: No decreased hearing, tinnitus, pain.Nose: No epistaxis, sinusitis.Throat and mouth: Infrequent sore throats.Chest: No wheezing, hemoptysis, sputum.Heart: No palpitation. No history hypertension.GU: No history haematuria, urgent micturition. No history venereal disease.Neuromuscular: No syncope, vertigo, dysesthesias, seizures. No history emotional disease.PHYSICAL EXAMINATIONDec. 21, 20039:30 A.M.General: Normal development, good nutrition, normal facial feature, free expressing, active position, normal gait, normal consciousness, cooperate examination.Weight and height: Not examined.Vital Signs: T38℃, P90 regular, R22BP R arm sitting: 100/60 mmHgSkin: Warm and dry. No stained yellow, no cyanosis, no pigmentation, no varicosity, no spider angioma, no bleeding, hair normal, no hepatic palm.Nodes: Auricular anterior, retroaurlcular, mastoid, occipital, cervical posterior, submandibular, cervical anterior, supraclavicular, axillaries, epitrochlear, inguinal, popliteal lymph nodes are not tactile.Head: Normocephalic, without trauma.No scars, tenderness, bruits.Eyes: Eyelids: No swelling, no drooping, no trichiasis.Conjunctivae: No swelling, no bleeding, no hyperemia.Eyeballs: Movement normal, without abnormal exophthalmoses and enophthalmos.Sclera: No stained yellow.Cornea: Lucent, without blaze and nebula.Iris: Equal size and round bilaterally, direct and indirect light reflex exists, accommodation reflex exists, convergence reflex exists.Ears: Auricle without malformation, no typhus, external auditory, canal without abnormal secretion, left ear and right ear hearing test normal, mastoid without tenderness.Nose: No deformity, ventilation clear, nasal septum midline. Nasal mucosa normal, without inflammation, or polyps. Nasal cavity without obstruction bilaterally. Maxillary sinus, ethmoid sinus, frontal sinus without tenderness.Mouth: Lip ruddily, no pale, no cyanosis, mucous membrane ruddily, no ulcer, smooth, no tooth deletion, no artificial denture, no dental caries, gums no bleeding, no pyorrhea, tongue thrill, pharynx no redness and swelling, no tonsil enlargement, larynx phonation normal.Neck: Thyroid not enlarged and without nodules. Trachea midline. Jugular veins flat. Carotid normal pulse bilaterally, jugular veins and carotid without bruits.Chest and lungs: Chest wall contour normal, with symmetrical full expansion. No rib tenderness to palpation. Tactile fremitus normal. No percussion dullness. Lungs are clear to auscultation. There is no egophony over this area. No rub heard.Heart: Heart region no bulge, no retraction, no obvious apical impulse. Apical impulse at the 5th intercostals inside the left midclavicular 1 cm, range 2 cm, no thrill, no visible lift, no pericardial friction feeling. The heart boarder is in the table:right(cm) intercostal Left(cm)2.1 Ⅱ 2.32.2 Ⅲ3.52.4 Ⅳ 5.5Ⅴ7.5Heart rate 75 times per min, heart beats rhythm, heart sound powerful, no extra heart sound, no heart murmur, no pericardial friction sound.Abdomen: Slightly protuberant. No scars or visible masses. Venous pattern normal. Bowel sounds normal. No hepatic or splenic rubs. No bruits. Liver edges is not palpated, with positive Murphy’s sign. Lower abdomen tenderness, especially in McBurney point. No shifting dullness, fluid wave. No hernia.Anus, rectum and genital organs: Not examined.Spine and limbs: Normal activity, no deformity, no spinous process, no direct, indirect percussion pain. Normal muscular tone, dorsalateries of foot beat symmetrically.Nervous system: Corneal reflex normal. Abdominal wall reflex exists. Biceps, triceps, radial periosteal reflex symmetrical bilaterally. Knee jerk, Achilles’ jerk normal. Hoffmann sign negative. Brudzinski sign negative. Babinski sign negative. Gordan sign negative. Oppenheim sign negative. Kernig sign negative. Floating patella phenomenon negative.LABORATORY FINDINGSWBC21.5×109 /L, L Y% 12.9%, GR% 87.6%.IMPTESSIONSAcute appendicitisTREATMENT PLAN1.No eating or drinking, keep him in bed.2.Anti-inflammation, fluid replacement, and monitoring blood gas.3.Fnish all necessary tests to get enough data about body condition.4.Operating in time.。

英语 病例 模板.doc

英语 病例 模板.doc

CASEMedical Number: 682786 General informationName:Wang Runzhen Age: Forty threeSex: FemaleRace:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500Date of admission:Jan 11st, XXXXDate of record: 11Am, Jan 11st, XXXX Complainer of history: the patient herself Reliability: ReliableChief complaint: Right breast mass found for more thanhalf a month.Present illness: Half a month ago, the patient suddenly feltpain in her right chest when she put up her hand. Aftertouching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then thepain became more and more serious, so the patient went totumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.Past historyOperative history: Never undergoing any operation. Infectious history:No history of severe infectiousdisease.Allergic history: She was not allergic to penicillin or sulfamide.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 historyShe was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history:The first time when she was 14. Lasting 3 to 4 days every times and its cycle is about 30 days.Obstetrical history:Pregnacy 3 times, once nature production, abortion twice.Contraceptive history: Not clear.Family history: His parents have both died.Physical examinationT 36.4℃,P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position.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 enlarged.HeadCranium:Hair was black and 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 smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: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. Neither nipples nor skin were retracted. Elasticity was fine.Lungs:Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. 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 80/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 tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. 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 exanedInvestigationNo.Professional Examination There are a about 3*3*2 cm mass in outer-up field of her right breast. It is hard but no tendness. It can be moved and its surface is smooth. The skin of her breast is normal. Corresponding superficial lymph nodes don’t enlarge.History summary1.Patient was a teacher, female, 43 years old.2.Right breast mass found for more than half a month.3.No special past history.4.Physical examination showed no abnormity in lung, heart and abdoman. Information about her breast can be seen above.5. Shorting of investigation information.Impression: Breast cancer (right)Signature: He Lin(95-10033)。

英文病历书写范例

英文病历书写范例

英文病历书写范例(内科)Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary 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 sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory 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 nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary 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 mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. 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 imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here 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 mur murs. 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 exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结(DISCHARGE SUMMARY), ===============Department of GastroenterologyChanghai Hospital,No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。

英文完全病历模板-详细版

英文完全病历模板-详细版

Admission RecordName:* Nativity: * district, * citySex:male Race: HanAge:55 Date of admission:2020-09-07 14:30 Marital status: be married Date of record:2020-09-07 15:23 Occupation:teacher Complainer:patient himself Medical record Number: * Reliability: reliablePresent address: NO*, building*, * village,* district, *city, *provinceChief complaint: cough and sputum for more than 6 years, worsening for 2 weeksHistory of present illness: The patient complained of having paroxysmal cough and sputum 6 years ago. At that time, he was diagnosed as “COPD” in another hospital and no regular treatment was applied. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago with no inducing factors. Small amounts of white and mucous sputum were hard to cough up. Compared to daytime, tachypnea worsened in the night or when sputum can’t be cough up. The patient can’t lie flat at the night because of prominent tachypnea and prefer a high pillow. He had no fever, no chest pain, no dizziness, no diarrhea, no abdominal pain, no obvious decrease of activity tolerance. On 20*-0*-*, the patient went to *Hospital for medical consultation. CT lung imaging indicated: lesion accompanied by calcification in the superior segment, the inferior lobe of the right lung, the possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in the inferior lobe of the left lung; arteriosclerosis of coronary artery.Pulmonary function tests indicated:d obstructive ventilation dysfunction; bronchial dilation test was negative2.moderate decrease of diffusion function, lung volume, residual volume and the ratio of lungvolume; residual volume were normalThe patient was diagnosed as “AECOPD” and prescribed cefoxitin to anti-infection for a week, Budesonide and Formoterol to relieve bronchial muscular spasm and asthma,amb roxol to dilute sputum, and traditional Chinese medicine (specific doses were unknown).The patient was discharged from the hospital after symptoms of cough and sputum slightly relieved with a prescription of using Moxifloxacin outside the hospital for 1 week. Cough and sputum were still existing, thus the patient came to our hospital for further treatment and the outpatient department admitted him in the hospital with “COPD”. His mental status, appetite, sleep, voiding, and stool were normal. No obvious decrease or increase of weight.Past history: The patient was diagnosed as type 2 diabetes 1 years ago and take Saxagliptin (5mg po qd) without regularly monitoring the levels of blood sugar. The patient denies hepatitis, tuberculosis, malaria, hypertension, mental illness, and cardiovascular diseases. Denies surgical procedures, trauma, transfusion, food allergy and drug allergy. The history of preventive inoculation is not quite clear.Personal history: The patient was born in *district, * city and have lived in * since birth. He denies water contact in the schistosome epidemic area. Smoking 10 cigarettes a day for 20 years and have stopped for half a month. Denies excessive drinking and contact with toxics.Marital history: Married at age of 27 and have two daughters. Both the mate and daughters are healthy.Family history: Denies familial hereditary diseases.Physical ExaminationT: 36.5℃ P:77bpm R: 21 breaths/min BP:148/85mmHgGeneral condition:normally developed, well-nourished, normal facies, alert, active position, cooperation is goodSkin and mucosa: no jaundiceSuperficial lymph nodes: no enlargementHead organs: normal shape of headEyes:no edema of eyelids; no exophthalmos; eyeballs move freely; no bleeding spots of conjunctiva; no sclera jaundice; cornea clear; pupils round, symmetrical in size and acutely reactive to light.Ears: no deformity of auricle; no purulent secretion of the external canals; no tenderness over mastoidsNose: normal shape; good ventilation;no nasal ale flap; no tenderness over nasal sinus; Mouth: no cyanosis of lips; no bleeding spots of mouth mucosa; no tremor of tongue; glossy tongue in midline; no pharynx hyperemia; no enlarged tonsils seen and no suppurative excretions; Neck: supple without rigidity, symmetrical; no cervical venous distension; Hepatojugular reflux is negative; no vascular murmur; trachea in midline; no enlargement of thyroid glandChest: symmetrical; no deformity of thoraxLung:Inspection:equal breathing movement on two sidesPalpation: no difference of vocal fremitus over two sides;Percussion: resonance over both lungs;Auscultation: decreased breath sounds over both lungs; no dry or moist rales audible; no pleural friction rubsHeart:Inspection: no pericardial protuberance; Apex beat seen 0.5cm within left mid-clavicular at fifth intercostal space;Palpation: no thrill felt;Percussion: normal dullness of heart bordersAuscultation: heart rate 78bpm; rhythm regular; normal intensity of heart sounds; no murmurs or pericardial friction sound audiblePeripheral vascular sign: no water-hammer pulse; no pistol shot sound; no Duroziez’s murmur; no capillary pulsation sign; no visible pulsation of carotid arteryAbdomen:Inspection: no dilated veins; no abnormal intestinal and peristaltic waves seenPalpation: no tenderness or rebounding tenderness; abdominal wall flat and soft; liver and spleen not palpable; Murphy's sign is negativePercussion: no shifting dullness; no percussion tenderness over the liver and kidney regionAuscultation: normal bowel sounds.External genitalia: uncheckedSpine: normal spinal curvature without deformities; normal movementsExtremities: no clubbed fingers(toes); no redness and swelling of joints; no edema over both legs; no pigmentation of skins of legsNeurological system: normal muscle tone and myodynamia; normal abdominal and bicipital muscular reflex; normal patellar and heel-tap reflex; Babinski sign(-);Kerning sign(-) ; Brudzinski sign(-)Laboratory DataKey Laboratory results including CT imaging and pulmonary function test have been detailed in the part of history of present illness.Abstract*, male, 55 years old. Admitted to our hospital with the chief complaint of cough and sputum for more than 6 years, worsening for 2 weeks. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago. The patient can’t lie flat in the night because of prominent tachypnea and prefer a high pillow.Physical Examination: T: 36.5℃,P: 77bpm, R: 21 breaths per minute, BP:148/85mmHg. Decreased breath sounds over both lungs; no dry or moist rales audible.Laboratory data: CT lung imaging indicates: lesion accompanied by calcification in superior segment, inferior lobe of right lung, possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in inferior lobe of left lung. Pulmonary function tests indicate: mild obstructive ventilation dysfunction, bronchial dilation test was negative moderate decrease of diffusion function.Primary Diagnosis:1.AECOPD2.Type 2 Diabetes3.Primary Hypertension Doctor’s Signature:。

英文病例模版

英文病例模版
Nose:The appearanceis normal,aerationis well.No abnormal
discharges were found invetibulum nasi. Septum nasi was in midline. No
nares flaring. No tenderness in nasal sinuses.
Superficial lymph nodes:Superficial lymph nodes were not found enlarged.
Head:Cranium:Hair was black and white, well distributed.No deformities. No scars.No pain when we press on. No masses.No tenderness.
Kinetic system:No history of joint pain, numbness,red and swollen,
metallaxis,myalgia or myophagism.
Neural system:No history of long-term headache,dizziness and vertigo,
atage 46.
Marital history:She’s marriedat 28,her husband is heslth,and the relationship
between them were concord.
Childbearing history:G4P2,induced abortion twice,natural labourtwice,and they are heathy.

英文病例汇报范文

英文病例汇报范文

英文病历文章病例写作是医生日常的工作。

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 S/E(systems inquiry)系统回顾General 一般情况 Fatigue lately, appetite unchanged, weight stable, no sweats or pruritus, sleeping well 最近有疲劳感,食欲无改变,体重稳定,无出汗或骚痒,睡眠佳。

英文病历书写

英文病历书写

过饱的人 a heavy (great; hard) eater
食量 capacity for eating
ex1:他的食欲良好,但他平常的吃食习惯,由于口里伤处而中断。
His appetite was good, but the sore place in his mouth interrupted his usual eating habit.
没有发烧 be afebrile; have no fever
ex1:在发烧期间,他的平均体温是摄氏39度。
He ran a febrile course with an average temperature of 39°C.
ex2:他在患病期间尿量减少,并且发烧。
发烧
发烧 become feverish; have a temperature
发高烧 have a high fever
平常有微热,有几次升到38.4度 have low grade (slight) fever to 38.4°C on a few occasions
(2)他诉说非常口渴,但一点食欲也没有。
He complains of his thirst hard to release, while he has absolutely no appetite.
口渴
口渴 be (feel) thirsty form
ex2:他的胃口变得很大,食物热量增加2倍,但体重却减轻了10公斤。
His appetite became ravenous and his caloric intake doubled, yet he lost 10 kg.
英文病历书写——睡眠

[宝典]英文病历示例

[宝典]英文病历示例

英文病历示例患者,李华,男,69岁,退休教师,因心悸一年,加重5个月于1989年6月6日入院。

一年前患者健康。

1988年5月感到轻微心悸,在工作劳累,快走及上楼时感气短,傍晚下肢浮肿,休息后则减轻。

近5个月来,心悸气短明显加重。

以致不能行走,亦不能平卧,不得不坐着度过整夜,有时咳嗽,咳少量白色粘液,无血。

患者无寒战、发热、胸痛或关节疼痛,排尿正常。

系统复习无特殊,1949年曾患“大叶肺炎”,无药物过敏史。

个人史:生在西安,曾去过中国南方,但无疫水接触史,抽烟一天10支,1945年结婚,其妻健康,有一女孩亦健康,其父死于胃癌,其母健在。

查体:体温36.8℃,脉搏90次/分,呼吸28次/分,BP23.5/13.3kPa,发育良好,营养中等,体胖、半卧位,颜面苍白,全身浮肿,神智清楚,查体合作。

皮肤无红斑、黄疸、紫瘢。

淋巴结未触及。

头部、眼、鼻、耳、口正常,但口唇紫绀。

颈软,颈静脉无充盈,甲状腺未触及,无细震颤或搏动,气管正中。

胸廓两侧对称,呼吸动度对称,无异常浊音区,但在两肺底部可闻一些湿罗音。

心尖搏动所见,触诊时在第5肋间,距正中线14cm处,无细震颤,心浊音界如图:心率90次/分,律齐,心尖部可闻Ⅱ级柔和的吹风样收缩期杂音,P2>A2,无胸膜磨擦音,腹软,无压痛及反跳痛,肝可触及,在肋下2cm,轻度压痛,脾未触及;无移动性浊音,其他正常。

右(cm)左(cm)1.5 Ⅱ2.02.0 Ⅲ 4.03.0 Ⅳ8.0Ⅴ14.0Ⅵ14.0正中线至左锁骨中线距离10cm初步诊断:1.高血压心脏病2.Ⅲ度心衰AN EXAMPLE OF MEDICAL CASE RECORD IN ENGLISHPatient Li Hua, mate,69 years old, a retired teacher, was admitted on June 6,1989,because of palpitation for one year and becoming worse in recent 5 months.The patient was quite well until one year before May,1988, He felt slight palpitation and dyspnia during hard work, fast walk , or climbing stairs, There was swelling of legs in the evening but he felt better after having a rest. In recent 5months, palpitation and dyspnia became so serious that he could neither walk nor lie down. He had to sit up during the whole night, Sometimes he coughed with small amounts of sputum, but without blood. He had no chill, fever, chest pain or sore joints. The urinating was normal.There was nothing else abnormal in the case history review except a cured lobor pneumonia in 1949. He had no history of drug allergy.Personal history:The patient was born in Xi’an in 1923. He had been to the south of China but did not contact contaminated water. He smoked a bout 10 cigarettes daily. He got married in 1945. His wife was healthy .They had a daughter who was also healthy. His father died of stomach cancer. His mother was well.Physical Examination:T.36.8C, P. 96/min, R. 28/min, BP.23.5/13.3kPa. The patient, an old fatty man who developed well and moderately nourished, was lying in bed with a semifallous position. He looked pale and suffered from general edima. He was mentally normal and cooperative in the examination. There was no eruption, no jaundice, no purpura on the skin, and the lymphnodes were not palpable. The head, eyes, nose, ears, mouth were normal while the lips were cyanotic. The neck was soft, there was no venous engorgement. Thyroid glands were not palpable, there were no thrill or brunt. The trachea was in midline. The chest and respiratory movements were symmetrical. There was no abnormal dullness but some moist rales were heard in the base areas of the both lungs. The points of maximal impulse (PMI) were not visible but palpable in the 6 thcostal interspace, 14cm form the middle line, there was no thrill. The cardiac dullness, 14cm from the middle line, there was no thrill. The cardiac dullness were as follows;Right (cm)I nterspaces Left (cm)1.5 Ⅱ2.02.0 Ⅲ 4.03.0 Ⅳ8.0Ⅴ10.0Ⅵ14.0The distance from midsternal line to midclavicular line was 10cm.The heart rate was 96/min, regular. There was a grade Ⅱsoft blowinglike systolic murmurat the apex,P2>A2, but no pericardium friction sound was heard. Abdominal wall was soft without tenderness. The liver was palpable 2cm below the costal margin with slight tenderness. The spleen was not palpable and there was no shifting dull ness. The rest was normal.Impression:disease with:1. hypertensive heart disease2.degreeⅢheart failureSignature:×××。

医学英语病历写作范文

医学英语病历写作范文

医学英语病历写作范文Chief Complaint: Left leg pain with recent fall.History of Present Illness: The patient is a 65-year-old male who presents to the emergency department with a chief complaint of left leg pain. He states that he fell down a flight of stairs approximately 3 hours prior to presentation. He reports that he is in moderate to severe pain, which is localized to his left lower extremity. He denies any associated numbness or tingling. He has no prior history of leg pain or injury.Past Medical History: The patient has a history of hypertension, which is well-controlled with medication. He has no other significant medical history.Social History: The patient is married and has two children. He is a retired construction worker. He smokes one pack of cigarettes per day and drinks alcohol socially.Family History: The patient's father has a history of coronary artery disease. His mother has a history of Alzheimer's disease.Physical Examination:Vital signs: Blood pressure 140/80 mmHg, heart rate 80 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F (37°C).General: The patient is in moderate distress due to pain. He is alert and oriented to person, place, and time.HEENT: Normocephalic and atraumatic. Pupils are equal and reactive to light. Extraocular movements are intact. No conjunctival injection or discharge. Tympanic membranes are intact and mobile.Neck: Supple with full range of motion. No masses or tenderness.Chest: Auscultation reveals clear breath soundsbilaterally. No wheezes, rales, or rhonchi.Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.Abdomen: Soft and non-tender. No masses or organomegaly.Extremities: Left lower extremity: Examination reveals swelling and tenderness of the left knee. There is a palpable step-off deformity of the lateral aspect of theleft knee. Active and passive range of motion is limiteddue to pain. Distal pulses are palpable and capillaryrefill is brisk. Sensation is intact. Right lower extremity: Examination reveals no abnormalities.Neurological Examination:Mental status: Alert and oriented to person, place,and time. No deficits in attention, memory, or language.Cranial nerves: No deficits.Motor: Strength is 5/5 in both upper and lower extremities. No atrophy or fasciculations.Sensory: Sensation is intact to light touch, pinprick, and temperature in all four extremities.Diagnostic Studies:X-ray of the left knee: The X-ray shows a displaced lateral tibial plateau fracture.Assessment:Left knee pain.Displaced lateral tibial plateau fracture.Plan:The patient will be admitted to the hospital for further evaluation and treatment.He will be placed in a knee immobilizer and will be started on pain medication.Orthopedic surgery will be consulted for further management.。

英文大病历

英文大病历

The following information was translated from the original medical file.Name : Weimin luqiU Place of birth: ShanghaiAge: 45 Nationality: HanMarital status :unmarried Admission time: Jan.8th ,2010 15:43:41 Occupation: engineerChief complaint: Coma for half an hour after head trauma, headache and dizziness for one day after regaining consciousness.History of present illness: patient fall down to the ground when he was riding on a bicycle at the noon of yesterday. He injured head, right shoulder and limbs. Patient lost consciousness immediately and this lasted for half an hour. After regaining consciousness, he could not remember the process of the injury and felt dizziness and ache. No nausea, vomiting, chest distress, abdominal distension, abdominal pain, convulsion or incontinence. Patient was sent to SAN SHUI Hospital, the head CT scan showed: subdural hematoma over right temporal region, fracture of temporale. X-ray over right shoulder and knee joint showed: no fracture. Patient was transferred to our hospital for further treatment. Patient’s mental status stable, he had bad appetite, normal bowel motion and urination. Upon admission: Texture of tongue and coated tongue is normal. Wiry pulse.Past medical history: PMH is insignificantReview of systems:HEENT: No photophobia, no tearing against wind or purulent nasal discharge. No decreased smelling and hearing, toothache.Respiratory: No cough, expectoration, hemoptysis or difficulty breathing. Cardiovascular: No palpitation, tachypnea, cyanosis, chest pain or swelling of extremities.Hematology: No dizziness, nosebleed, gingiva bleeding or ecchymosis. Genitourinary: No urgent or frequency in urination, pain in urination or dysuria. No increased nocturia or facial edema.Musculoskeletal: No limb deformity, joint swelling. Range of motion were normal.Gastrointestinal: No abdominal pain, diarrhea , sour regurgitation or belching. Endocrine: No excessive thirst, excessive food intake or excessive sweat. Neurological: No headache or dizziness.Social history: Born and live in Shanghai, never been to epidemic area of infectious disease. No contact history of bird flu, SARS. Non smoker. Non drinker. He lived regular life.Allergy history: No known allergiesMarital status : unmarriedFamily history: FM is insignificant.Physical examination:Vital signs: T 36.6℃, P 76bpm, RR 20/min, BP120/65mmHgGeneral: well developed, well nourished, alert ,spontaneous position, cooperates well with doctor.Skin: No jaundice, cyanosis, rash, ecchymosis or operative scars were detected all over the body.Lymph node: No superficial lymph node were detected.Neck: supple, no distention of jugular vein, no abnormal carotid artery pulse thyroid gland not enlarged, no nodules detected. Trachea was in the midline.Chest: chest wall were symmetry, bilateral breath sounds clear, no rales or rhonchus detected. No precordial abnormal protrusion, apical impulse lies in the fifth intercostals space, 2 centimeters medial to the left medioclavicular line, HR80bpm, rate and rhythm regular. No murmursAbdominal: flat. No gastrointestinal type or peristaltic wave. No abdominal venous engorgement. Abdominal breathing was not limited. No tender, rebound or guarding. Liver border were normal. Liver and spleen were not palpated. Murphy’s sign(-), no shifting dullness. No tender or percussion pain over bilateral renal region. Normal bowel sounds. No vascular murmurs. Musculoskeletal: Physiological bending of spine, non tender or percussion pain, multiple bruises over right shoulder, left opisthenar and right knee. Skin reddened over these areas, tenderness without obvious exudation. Normal muscular tone and muscular strength, normal function of joints. No joint swelling. Range of motion normal. No edema over lower limbs. No venous vasodilator.Neurological: No pathologic reflex were noted.Neurological examination: patient alert and oriented , mental status stable. Retrograde amnesia. No deformity of head . Bruises over frontal region can be seen and skin reddened of these areas with obvious tender. Right conjunctiva congestion and swelling. No decreased hearing. Bilateral pupils equally roundand reactive to light (with diameter 1.5mm). External ear canal no red, swelling or abnormal excretion, mastoid has no tenderness. Shape of nose is normal, No nasal ala flap no tender. Lip has no pallor, no cyanosis, oral mucosa is smooth. Tongue was midline protrusion. Pharynx no congestive, tonsils no enlarged. Neck supple. Normal muscular tone and muscular strength. Physiological reflex normal, no pathologic reflex were noted.Lab test:Jan.8th ,2010 head CT scan: subdural hematoma over right temporal region, fracture of ossa temporale.X-ray over right shoulder and knee joint showed: no fracture can be seen Admission diagnosis:TCM diagnosis: head injury (air-stagnancy and blood stasis)Diagnosis by western medicine: head injury: subdural hematoma over right temporal region; fracture over right temporale and basicranial; head bruises(right temporal region);multiple soft tissue injury over right shoulder, right hand and right knee.Confirming diagnosis:TCM diagnosis: head injury(air-stagnancy and blood stasis)Diagnosis by western medicine: head injury: subdural hematoma over right temporal region; fracture over right temporale and basicranial; head bruises(right temporal region);multiple soft tissue injury over right shoulder, right hand and right knee.Dr. ZHANG。

四年级英语病历范文

四年级英语病历范文

四年级英语病历范文Patient Name: Zhang SanAge: 10 years oldDate of Visit: October 10th, 2023Chief Complaint:The patient complains of a sore throat, cough, and runny nose for the past three days.History of Present Illness:The patient's symptoms started three days ago with a sore throat, followed by a cough and runny nose. The cough is dry and persistent, and the patient has been experiencing some difficulty swallowing due to the sore throat. There is no history of fever, chills, or ear pain. The patient's appetite has decreased, and there is a mild decrease in energy levels.Past Medical History:The patient has a history of seasonal allergies, with symptoms of sneezing and itchy eyes during the spring andfall seasons. There is no history of asthma or other chronic respiratory conditions.Family History:There is no significant family history of respiratory illnesses or other chronic conditions.Medications:The patient is not currently taking any medications.Allergies:The patient has no known drug allergies.Review of Systems:- Constitutional: Decreased appetite and energy levels - Respiratory: Sore throat, cough, runny nose- Gastrointestinal: No nausea, vomiting, or diarrhea - Musculoskeletal: No joint pain or swellingPhysical Examination:- Vital Signs: Temperature 98.6°F, pulse 80 beats per minute, respiratory rate 20 breaths per minute, blood pressure 110/70 mmHg- General: The patient appears fatigued, but alert and oriented- Head and Neck: Erythematous pharynx, no tonsillar exudates, clear nasal discharge- Respiratory: Lungs clear to auscultation bilaterally - Cardiovascular: Regular rate and rhythm, no murmurs or gallops- Abdomen: Soft, non-tender, non-distendedAssessment:Based on the patient's history and physical examination, the likely diagnosis is an upper respiratory tract infection, possibly viral in nature.Plan:1. Symptomatic treatment for sore throat and cough, including acetaminophen for pain and discomfort2. Encourage increased fluid intake and rest3. Monitor for any signs of worsening symptoms, such as persistent high fever or difficulty breathing4. Follow up in three days if symptoms do not improve or worsen中文回答:患者张三,10岁,主诉三天来咽喉痛、咳嗽和流鼻涕。

英语 病例 模板

英语 病例 模板

CASEMedical Number: 682786 General informationName:Wang Runzhen Age: Forty threeSex: FemaleRace:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500Date of admission:Jan 11st, 2001Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: ReliableChief complaint: Right breast mass found for more than half a month.Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.Past historyOperative history: Never undergoing any operation. Infectious history:No history of severe infectiousdisease.Allergic history: She was not allergic to penicillin or sulfamide.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 historyShe was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history:The first time when she was 14. Lasting 3 to 4 days every times and its cycle is about 30 days.Obstetrical history:Pregnacy 3 times, once nature production, abortion twice.Contraceptive history: Not clear.Family history: His parents have both died.Physical examinationT 36.4℃,P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position.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 enlarged.HeadCranium:Hair was black and 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 smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: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. Neither nipples nor skin were retracted. Elasticity was fine.Lungs:Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. 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 80/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 tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. 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 exanedInvestigationNo.Professional Examination There are a about 3*3*2 cm mass in outer-up field of her right breast. It is hard but no tendness. It can be moved and its surface is smooth. The skin of her breast is normal. Corresponding superficial lymph nodes don’t enlarge.History summary1.Patient was a teacher, female, 43 years old.2.Right breast mass found for more than half a month.3.No special past history.4.Physical examination showed no abnormity in lung, heart and abdoman. Information about her breast can be seen above.5. Shorting of investigation information.Impression: Breast cancer (right)Signature: He Lin(95-10033)。

病例英语作文

病例英语作文

病例英语作文Title: A Case Study: Understanding the Symptoms and Treatment of Common Cold。

Introduction:In this case study, we delve into the symptoms, diagnosis, and treatment of the common cold. The common cold, caused primarily by rhinoviruses, is one of the most prevalent infectious diseases worldwide. Understanding its presentation and management is crucial for healthcare professionals.Case Presentation:The patient, a 28-year-old male, presented with a two-day history of nasal congestion, runny nose, sneezing, sore throat, and mild cough. He reported experiencing fatigue and malaise but denied any fever or significant respiratory distress. Upon physical examination, clear nasal discharge,erythematous throat without exudates, and mild bilateral tympanic membrane erythema were noted. His vital signs were within normal limits.Diagnosis:Based on the clinical presentation and absence of significant findings on physical examination, the patient was diagnosed with a common cold. Laboratory tests, including complete blood count and throat swab forbacterial culture, were not indicated due to the typical viral etiology of the illness.Treatment:The management of the common cold primarily involves supportive care and symptom relief. The patient was advised to rest, maintain adequate hydration, and use over-the-counter medications for symptom relief. He was prescribed a combination of acetaminophen for pain and fever, pseudoephedrine for nasal congestion, and dextromethorphan for cough suppression. Additionally, saline nasalirrigation and throat lozenges were recommended for symptomatic relief.Follow-up:The patient was advised to follow up if symptoms worsened or persisted beyond ten days. He was educated on the importance of hand hygiene and respiratory etiquette to prevent the spread of the virus to others. Furthermore, he was counseled on the limited efficacy of antibiotics in treating viral respiratory infections and the potential risks of antimicrobial resistance associated with their misuse.Discussion:The common cold is a self-limiting viral infection characterized by upper respiratory tract symptoms. While often benign, it can cause significant morbidity and economic burden due to missed work and healthcare utilization. Rhinoviruses are the primary pathogens responsible for the common cold, although other virusessuch as coronaviruses and adenoviruses can also contribute.Management of the common cold focuses on relieving symptoms and supporting the body's natural immune response. Antiviral medications are not routinely recommended for the treatment of the common cold due to limited efficacy and potential side effects. Instead, symptomatic relief with over-the-counter medications and home remedies remains the mainstay of therapy.Preventive measures such as hand hygiene, avoiding close contact with sick individuals, and vaccination against influenza can help reduce the risk of acquiring and spreading the common cold. Despite these efforts, the high variability of circulating viral strains and the lack of cross-protection against all respiratory viruses pose challenges to prevention strategies.Conclusion:In conclusion, the common cold is a ubiquitous viral infection with a characteristic clinical presentation.Understanding its symptoms, diagnosis, and management is essential for healthcare providers to provide appropriate care and educate patients on preventive measures. By emphasizing supportive care and symptom relief, healthcare professionals can help minimize the impact of the common cold on individual patients and public health.。

英语病例

英语病例

CASEMedical Number: 682786 General informationName:Wang RunzhenAge: Forty threeSex: FemaleRace:HanOccupation: Teacher Nationality:ChinaMarital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei Date of admission:Jan 11st, 2001Date of record: 11Am, Jan 11st, 2001Complainer of history: the patient herselfReliability: ReliableChief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too. Past historyOperative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide. 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 historyShe was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history:The first time when she was 14. Lasting 3 to 4 days every times and its cycle is about 30 days.Obstetrical history:Pregnacy 3 times, once nature production, abortion twice.Contraceptive history: Not clear.Family history: His parents have both died.Physical examinationT 36.4℃, P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position. 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 enlarged. HeadCranium: Hair was black and 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 smooth, and of no ulcer or erosion.Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: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. Neither nipples nor skin were retracted. Elasticity was fine.Lungs:Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. 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 80/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 tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. 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 exanedInvestigationNo.Professional ExaminationThere are a about 3*3*2 cm mass in outer-up field of her right breast. It is hard but no tendness. It can be moved and its surface is smooth. The skin of her breast is normal. Corresponding superficial lymph nodes don’t enlarge.History summary1.Patient was a teacher, female, 43 years old.2.Right breast mass found for more than half a month.3.No special past history.4.Physical examination showed no abnormity in lung, heart and abdoman. Information about her breast can be seen above.5. Shorting of investigation information.Impression: Breast cancer (right) Signature: He Lin (95-10033)。

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PRESENTATION of CASEDr. Patricia L. Musolino (Neurology): An 18-year-old man was transferred to this hospital because of blurred vision, dysarthria, and ataxia, which had reportedly progressed to coma.The patient had been well until 6 p.m. the evening before admission, when he had an abrupt onset of weakness, shaking and buckling of his legs, and clumsiness of his right hand. Approximately 20 minutes later, his speech became slurred; his parents transported him to the emergency department at another hospital. While in transit, the dysarthria worsened and the patient reported blurred vision. On arrival at the hospital 1 hour after the onset of symptoms, he required assistance getting into a wheelchair. He reported being off-balance and light-headed, with blurred vision and pain at the base of the right side of the skull. On examination, he was alert and oriented but slow to respond, and he intermittently laughed inappropriately. The vital signs were normal, and the oxygen saturation was 100% while he was breathing ambient air. On neurologic examination, the pupils and extraocular movements were reportedly normal, without nystagmus. The speech was slurred. The first cranial nerve was not tested; results of testing of the other cranial nerves were normal. The deep-tendon reflexes were 1+ and symmetric. Alternating movements of the hands were slow, with some lack of coordination; his performance on finger-to-nose testing was accurate.The white-cell count was 8600 per cubic millimeter, with 80% granulocytes, 14% lymphocytes, and 6% monocytes. The remainder of the complete blood count and the results of renal- and liver-function tests were normal, as were the levels of electrolytes and glucose, measurements of arterial blood gases performed while the patient was breathing ambient air, and other test results. Screening of the blood for alcohol and the urine for toxins and drugs was negative. Computed tomography (CT) of the head was reportedly normal. The patient was admitted to the other hospital. A lumbar puncture was performed; tube 1 of the cerebrospinal fluid (CSF) appeared bloody, with gradual clearing. Reportedly, the white-cell count was 9 per cubic millimeter in tube 1 and 1 per cubic millimeter in tube 4, and the red-cell count was 10,000 per cubic millimeter in tube 1 and 54 per cubic millimeter in tube 4. The protein level was 58 mg per deciliter, and the glucose level 62 mg per deciliter (3.4 mmol per liter). No organisms were seen on Gram's staining.Overnight, the patient frequently flailed his arms and legs, according to his mother. On examination the next morning, he was alert, oriented, communicative, and restless, with intermittent movements of the arms; strength was normal, eye movements were full, pupils were reactive, and there was mild ataxia. At approximately 11:30 a.m., difficulty walking developed, violent shaking of his legs and arms began, and he became unable to speak. Magnetic resonance imaging (MRI) performed 30 minutes later, after the administration of lorazepam (5 mg in 1-mg increments to decrease motion artifact),reportedly revealed abnormal signal changes in the brain stem.The patient was transferred to the intensive care unit (ICU) at the other hospital. On examination, he was somnolent but arousable to painful stimuli. During the next 3 hours, he appeared to see and hear his mother but was unable to speak. Shortly before transfer to this hospital, extensor posturing with clenched fists and rigid arms developed. On arrival of the transport team, succinylcholine, propofol, rocuronium, and fentanyl were administered and the trachea was intubated. The patient was transported by helicopter to this hospital, arriving approximately 23 hours after the onset of symptoms. Lorazepam and additional fentanyl were administered in transit.The patient's history of birth and development was normal, and he had been previously healthy, with a learning disability. He had been scratched by a neighbor's dog 3 weeks before admission; the vaccination status of the dog was unknown, but the animal continued to appear well. Approximately 2 days before admission, the patient had removed an embedded tick, which was not engorged, from his skin. He took no medications and had no allergies. He lived with his family, had attended 3 years of high school, and worked in a service position. His grandfather and mother had had transient ischemic symptoms, a maternal aunt had died of neuronal ceroid lipofuscinosis, and a half-sibling had a learning disability.The patient was admitted to the pediatric ICU at this hospital. On examination, he was mechanically ventilated with an endotracheal tube. There was tonic deviation of the head to the left side. The pupils were 3 mm in diameter and weakly reactive, corneal reflexes were present, and there was no oculocephalic reflex. The tone in the arms was slightly increased, and they were held in the extended position. The fingers were firmly flexed but without Hoffmann's sign (flexion of the terminal phalanx of the thumb and of the second and third phalanges of another finger on tapping the index, middle, or ring finger). The legs were extended and tremulous, with greatly increased extensor tone. There was sustained clonus, and the plantar reflexes were extensor. The patient responded to noxious stimulation with increased extension of the arms and triple flexion (hip, knee, and ankle) of the legs. The remainder of the examination was normal.The white-cell count was 10,900 per cubic millimeter (reference range, 4500 to 13,000), with 85% neutrophils (reference range, 40 to 62), 9% lymphocytes (reference range, 27 to 40), and 6% monocytes (reference range, 6 to 11); the serum level of phosphorus was 0.9 mg per deciliter (0.3 mmol per liter; reference range, 2.6 to 4.5 mg per deciliter [0.8 to 1.5 mmol per liter]); and results of coagulation and renal-function tests were normal, as were blood levels of hemoglobin, platelets,D-dimer, lactic acid, electrolytes, calcium, magnesium, lipase, amylase, total protein, and albumin.Ten minutes after admission, a diagnostic procedure was performed.sp-3.6.0bovidweb.cgi&S=BLIOPDPGMOHFDHNBFNPKADEGKDFDA A00&Link+Set=S.sh.26.27.31.62%7c17%7csl_10。

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