英文大病历文档格式.docx
《英文大病历文档格式.docx》由会员分享,可在线阅读,更多相关《英文大病历文档格式.docx(5页珍藏版)》请在冰豆网上搜索。
Dateofadmission:
February282003Dateofhistorytaking:
February282003
Narrator:
thepatientReliabilityofthehistory:
reliable
TheHistory
ChiefComplaint:
lumbagofor2yearswithweakness,numbnessinlowerlimbs,moresevere2months.
PresentIllness:
2yearsago,afterworking,thepatientalwaysfeltlumbago,sometimesreferredpainatthehipandlowerextremities,mainlyatthedorsalside.andtheleftlowerlimbwasmoresevere.Atthesametimehefeltweakandnumbatlowerlimbs,alsomoresevereintheleftside.Nomuscleatrophy,noabnormalofstoolandurine.Notemperatureabnormalorcolorchangesinthelocalskin.Nonailsdamaged.Thenthepatientwenttothehospitalinhistown,andhadaX-rayexamination,shownhypertrophyinthelumbarvertebrae.,givensomedrugsforpain-control.Afterhavingsomedrugsandmorerest,thesymptomslightened.But2monthsago,withoutsignificantcauses,thesymptomsbecamemoresevere.Thelumbagooftenmadehimsleeplessatnights.Andhecanonlywalk500meterswithoutabreak.hisleftlowerlimbfeltnumbandweak.
Havingthedrugsandrestbothcannoteasethesymptoms.Sohecametoourhospitalforadvanceddiagnosisandtreatment.Sincethedisease,nochangesinconsciousness
bodytemperature,appetite,bodyweight.andnormalofstoolandurine.
Pasthistory:
thepatienthadahistoryofhighintensiveworkingforabout10years.Nohistoryofchronicdiseaseslikehypertension,CADandmellitusdiabetics.NohistoryofhepatitisorAIDS,tuberculosis.Nohistoryoftraumaandoperation.Nohistoryofhypersensitivityofanydrugorfood.
ReviewofSystems:
Respiratorysystem:
nohistoryofchroniccough,expectoration,hemoptysis,chestpain,orshortofbreath.
Circulationsystem:
nohistoryofdyspneaoredemaatthelowerlimbs.Nohistoryofpalpitationorchestpain.Nodizziness,headache,Nohistoryofhypertension.
Digestivesystem:
nohistoryofanorexia,abdominaldistention,regurgitation.Nonauseaandvomiting.Nohistoryofconstipation,diarrhea,melenaandsoon.
Urogenitalsystem:
nohistoryofswolleneyelidsorlumbago.Nofrequentmicturition,urgencyofmicturitionorurodynia.Nodysuria,hematuriaorretentionandincontinenceofurine.nohistoryofacuteorchronicnephritis.
Hemopoelticsystem:
Nopallidcountenance,weakness,dizziness,daze,tinnitus.Nohistoryofbleedingandrepeatedinfections.Nohistoryofenlargementofliverandspleen.
MetabolicandEndocrinesystem:
noabnormalcoldorhotfeeling,hidosis,headacheweakness,impairedvision,polyphagia,polyuriaect.normaldistributedhair.nochangeoftemperandintelligence.
Nervoussystem:
Noheadache,projectilevomiting.nosyncope,spasm,impairedvision,abnormalsensationormotion.Nochangeofpersonality.nomania,depressionorhallucination.
Motorsystem:
lumbagoandlimitationofmovementfor2years.weaknessandnumbnessatlowerlimbs,theleftmoresevere.Nospasm,atrophyorpalalysis.Nojointredswollen,hot,painorlimitationofmotion.Notraumaorfracture.
Personalhistory:
borninhernativeplaceandlivinginTianjin.Nohistoryofexposuretopoison.Nohabitsofdrinkingorsmoking.
MaritalHistory:
.Marriedat24yearsoldandhavingachild.thechildandhiswifebothhealth.
Familyhistory:
denyingthefamilyhistoryofanyhereditydiseases,orMD,CAD,hypertensionect.
PhysicalExamination
Temperature:
36.5°
Cpulserate:
72/minrespiratoryrate:
18/minbloodpressure:
130/80mmHg
Generalappearance:
normaldevelopmentandmediuminnourished,noabnormalconsciousness,goodcorporationinexamination.Freeposition.
Skinandmucousmembrane:
Nopallid,cyanosis,andjaundice.noabnormalpigmentationanddepigmentation.noerythmaannulare,petechiaandspiderangioma.Normalelasticityofskin,noedema.
Superficiallymphnodes:
noenlargementofthesuperficiallymphnodes.
Headanditsorgans:
Skull:
nodeformity,tendernessormass.Evenlydistributedhairwithblackcolorandshine.
Eyes:
nodropoutofeyebrowandnomadarosis,noswollenorprolapseofeyelids.Nopallor,granules,folliclespectechiaeofconjunctivae.transparentofcornea,nonebula,keratoleukoma,malacia,ulcerorvascularization.Noexophthalmosorenophthalmos.freemotionsoftheeyeballsinanydirection.Equalandroundpupilsatbothsideswithdiameter4mm,normalandactivedirectandindirectlightreflexs,normalaccommodationandconvergencereflexes.Vision,visualfieldandeyegroudnotexamined.
Ears:
nodeformity.noabnormalsecretionfromexternalcanals.Nored,tenderness,swolleninthemastoid.Roughtestednormalhearing.
Nose:
nodeformity.Nodeviationofseptumnasi.Noalaflutter.Noedema,abnormalsecretion,andcongestionofthemembrane.goodventilation.Notendernessinanyparanasalsinuses.
Buccalcavity:
nopallidorcyanosisoflips,alsonodryness,herpessimplex.Nocongestion,petechiaorulcerinthebuccalmembrane.32teeth,nocaries.Nobleedingorcongestion,leadlineingums.Thinandslightyellowfurcoatedonthetongue,withnormalinmotion.Norednessandcongestioninpharynx,nodeviationofuvulae.Noedemaintonsils.
Neck:
symmetry.noenlargementofexternaljugularvein,noabnormalpulsationofcarotidarteriesorveins.Norigidity.noenlargementofthyroidglands,andthetracheainthecenteralposition.Nomurmur.Negativeofhepatojugularreflux.
Chest:
symmetry.Nodeformity.Nobarrelchest,pigeonchestorfunnelchest.Notendernessoverthechest.thethoracicrespirationpresent.R18/min,symmetryinbothsides.Symmetryandnoabnormalityofthe2breasts.
Lungs:
Inspections:
nobulgesorrecessionoftheintercostalsspacesduringrespiration.Respiratorymovementequalinbothsidesandregular.nodyspneaorthreeconcavesign.
Palpation:
symmetryrespiratorymovementinthetwosides,noincreaseordecreaseofvocalfremitus.Nopleuralfrictionfremitus.nosubcutaneouscrepitation.
Percussion:
resonanceinalloverthelungfields.5cminwidthofapexes,andthelowermarginoflungat6th,8th,10thonmidclavicular,midaxillary,midcapularlinerespectively.Themovementofthelowermarginofthelungs:
6cm..
Auscultation:
clearofvesicularbreathingsoundsalloverthelungfields.Nomoistralesorrhonchis.normalofvocalresonance.Nopleuralfrictionsound.
Heart:
Inspection:
noprecordialbulging.Apicalimpulseinthe5thICS1cminsideofleftmidclavicularlinewithanareaof2cmindiameter.
apicalimpulseanditsareaasthatininspection.Regular,normalintensity.Nopericardialfrictionrubsorthrill.
relativecardiacdullnessshownasfollows:
Right(cm)
ICS
Left(cm)
2
Ⅱ
Ⅲ
4
3
Ⅳ
6
Ⅴ
7
Thedistancebetweentheleftmidclvicularlineandthemidsternallineis8cm.
HR72/minwithregularrhythm,heartsoundsclearandintensive.nomurmursatanyauscultationareaofthevalvula.Nopericardicalfrictionsound.
Radialarteries:
pulserate85/min,withregularrhythm,equalinbothsides,normalintensity.
Perivascularsigns:
nocapillarypulsation,waterhammerpulse,pistol-shotsoundsandDuroziez’smurmur.nopulsedeficit,andpulsealternant.
Abdomen:
symmetry.Nobulgeabdomen,abdominaldistention.normalabdominalrespiration.Novisiblegastrointestinalwaves.Novaricosity,scar,petechiaattheabdominal
Skin.
soft,notendernessandreboundingtenderness,notightenedabdominalwall.Nopalpablemass.
Liver:
notpalpable.
Gallbladder:
notpalpable.Negativeofmurphy’ssign.
Kidneys:
notpalpable.Notendernessintheanysiteofkidneysorureters.
Spleen:
Appendix:
notendernessattheMcburney’ssite.
tympanyinallovertheabdomen,noshiftingdullness.Nopercussivepainofliverandspleen.Theuppermarginofliveratthe5thICSintherightmidcalvicularline
normalborhorygmus,4/min,nomurmurofvessels.Nofrictionrubs.
Anusandrectum:
notexamined.
Spine:
nolordosis,kyphosis,orscoliosis.tendernessandpunchingtendernessatthelevelofL3-L5.Limitationofmovement,especiallyanteflextion.Nochangesinthelocalskin.
Extremities:
symmetry,nodeformity.freemotion.nojoint.redness,swollen,tendernessorhotness.noedemainthelowerextremities.
myodynamiaofleftlowerlimbin4thgradeandrightlowerlimbin5-thgrade.Detailsinthespecialcondition.
Nervesystem:
numbnessinlowerlimbs,moresevereinleftside.Normalsensation.atotherplace.Biceps,triceps,radioperiosteal,andabdominalwallreflexesnormal.whilekneejerkandAchillesjerkactiver.babinski’s(+_)oppenheim’s,chaddock’s,gordon’snegative.Nopatellarorankleclonus.
Laboratoryfindings:
Bloodroutine:
WBC7.3*10ª
N0.65,L0.35,Hb141g/l.RBC4.38*1012/l,plt238*10ª
/l.
X-ray:
hypertrophyoflumbarvertebrae.
MRI:
theresultsnotgotten.
Specialcondition:
nolordosis,kyphosis,orscoliosisofspine.tendernessandpunchingtendernessatthelevelofL3-L5.Limitationofmovement,especiallyanteflextion.Nochangesinthelocalskins.extrmitiessymmetry,nodeformity.freemotion.nojoint.redness,swollen,tendernessorhotness.noedemainthelowerextremities.Musculartensionofleftlowerlimbin4thgradeandrightlowerlimbin5-thgrade.Sensationinleftlowerlimbdecreased.Biceps,triceps,radioperiosteal,andabdominalwallreflexesnormal.whilekneejerkandAchillesjerkactiver.babinski’s(+_)oppenheim’s,chaddock’s,gordon’sn