診斷學(xué)：病歷范例（英文）

1、THE AIDED TEXTBOOK OF DIAGNOSTICS THE EXAMPLES OF ADMISSION NOTE2012.2CATALOGRESPIRATORY SYSTEM NOTE2-10CARDIOVASCULAR SYSTEM NOTE11-20DIGESTIVE SYSTEM NOTE21-27URINARY SYSTEM NOTE29-37HEMATOLGIC SYSTEM NOTE 38-45ENDOCRINOLOGIC SYSTEM NOTE46-53ADMISSION NOTEPATIENTS NAME: Li AnBIRTH PLACE: Dali, Yun

2、nan ProvinceSEX: MaleADDRESS: No. 176, Yue Xiu Nan Road, Guangzhou.DATE OF BIRTH: Jan 5th, 1964DATE OF ADMISSION: June 8th, 2007RACE: HanDATE OF HISTORY TAKING: June 8th, 2007MARITAL STATUS: MarriedSOURCE OF HISTORY: PatientOCCUPATION: Auto repair workerRELIABILITY OF HISTORY: ReliableCHIEF COMPLAIN

3、T:Intermittent shortness of breath for 20 years and recurring attack for 1 weekHISTORY OF PRESENT ILLNESS:The patient, a 43-year-old male, complained of recurrent shortness of breath over the past 20 years. Attacks often occured in the early morning or in cold weather and could be triggered by eatin

4、g eggs. The symptom usually resolved in 10 minutes without treatment. In the incipient stage, the shortness of breath was not accompanied with cough and sputum and he could lie down without increasing difficulty in breathing. However, the symptom had been aggravated since 10 years before. He reporte

5、d recurrent shortness of breath accompanied by chest tightness, wheezing, cough, sneezing, itchy nose and sweating. He was more comfortable in sitting position than in supine position during attacks and symptoms usually were relieved in a few hours after expectoration of frothy sputum. Poor appetite

6、 and tiredness were noted during attacks but there had been no fever, palpitation, hemoptysis, pink frothy sputum and chest pain. He complained of shortened intervals between episodes and prolonged duration of attacks over the past years. He was quite normal between attacks. He was admitted to Guanz

7、hou First Municipal Peoples Hospital seven years ago and diagnosed as “asthma”. Cimaterol could relieve the symptoms quickly. However, since the weather got cold one week before he has been suffering from shortness of breath that could not be relieved by cimaterol. He visited Emergency Room in our h

8、ospital and was admitted for further evaluation and management. Throughout the course of illness, there has been no palpitation, edema, chest pain, afternoon fever, night sweat or body weight loss. Urination and defecation have been normal.PAST HISTORY:He had “scarlet fever” and was cured at the age

9、 of 11. He received surgery for “internal hemorrhoid” five years ago. No history of measles, typhoid fever, malaria, tuberculosis, hepatitis and other contagious diseases. Eating eggs can trigger shortness of breath. No history of drug allergy. No history of trauma. No history of blood transfusion.R

10、EVIEW OF SYSTEMS:Respiratory system: As described in history of present illness.Circulatory system: No history of palpitation, dyspnea on exertion, hemoptysis, lower limb edema, precordial pain, hypertension and syncope.Gastrointestinal system: No history of sour regurgitation, belching, dysphagia,

11、nausea, vomiting, abdominal distension, abdominal pain, conspitation, diarrhea, hematemesis, hemafecia and jaundice.Urinogenital system: No history of lumbodynia, frequent micturation, urgent micturation, dysuria, abnormal urinary production, facial edema and genital ulcer.Hematologic system: No his

12、tory of ochrodermia, debilitation, dizziness, blurred vision, gingival bleeding, epistaxis, subcutaneous hemorrhage, lymphadenectasis, hepatomegaly, splenomegaly and ostealgia.Endocrine system: No history of abnormal appetite, cold intolerance, polyhidrosis, polydipsia, polyuria, fine tremor, change

13、 in temperament, marked obesity, marked emaciation, hirsutism, hair loss, pigmentation and sexual disturbance.Musculoskeletal system: No history of arthralgia, joint swelling, arthrentasis, myalgia and myatrophy.Nervous system: No history of dizziness, headache, vertigo, syncope, hypomnesia, conscio

14、usness disturbance, shivering, convulsion, paralysis and paraesthesia.Psychiatric status: No history of illusion, delusion, disorientation and emotional disturbance.PERSONAL HISTORY:Principle place of residence: GuangzhouTravel history: He has never been to areas with risks of malaria, schistosomias

15、is paragonimiasis or other epidemic diseases.Education degree: Middle schoolOccupation: Auto repair workerSmoking: 12 cigarettes per day for 20 yearsAlcohol intake: No alcohol drinking habitSexual history: No history of venereal disease and unprotected sex.Financial status: FairMARITAL HISTORY:He go

16、t married at the age of 23. His wife is healthy. They had two sons.FAMILY HISTORY:His father died of “hypertensive intracerebral hemorrhage” at the age of 70. One of his younger brother has history of “asthma”. His mother, other siblings and his sons are healthy. He denied family history of heredita

17、ry diseases.PHYSICAL EXAMINATIONVital signs: Blood Pressure: 143/87mmHg Body Temperature: 37 Pulse Rate: 90 /min Respiration Rate: 30/minGeneral Appearance: Normal development, moderate nutritional status, orthopneic, acutely ill-looking, clear consciousness, cooperative.Skin and mucosa: Flushing, s

18、lightly cyanotic, no pallor, no jaundice, no pigmentation, no rashes, no subcutaneous hemorrhage, normal hair distribution, hyperhidrotic, moist skin, good skin elacticity, no edema, no liver palm, no spider angioma, no scar, no fistula, no nodule.Lymph node: No palpable preauricular, postauricular,

19、 mastoid, occipital, posterior cervical, anterior cervical, supraclavicular, axillary, epitrochlear, inguinal and popliteal lymph nodes;Head: no deformity, no tenderness, no lump, no scar, normal hair distribution, black and lustrous hair.Eye: Intact eyebrow hair, no eyelid edema, no ptosis, no lago

20、phthalmos, no exophthalmos, no enophthalmos, no nystagmus, no eyeball movement disorder; no conjunctival congestion, no conjunctival hemorrhage, no conjunctival edema, no conjunctival pallor, no pterygium; no icteric sclera; transparent cornea; pupils are equally round, 3mm in diameter; accommodatio

21、n reflex and convergence reflex are normal.Ear: No auricle deformity, no nodules, no pre-auricular fistula, no secretion in external auditory meatus, no tenderness on mastoid process, no hearing loss on rough test.Nose: No deformity; remarkable flaring of nares, no nasal obstruction, no abnormal exc

22、retion, no perforation of nasal septum, no deviated nasal septum, no hypertrophy of nasal turbinates, no sinus tenderness.Mouth: Red lips, no cyanosis, no pallor, no herpes, no chapped lips; normal mucosa, no pallor, no petechia, no ulcer; opening of parotid gland duct is normal, no swelling, no sup

23、purative excretions; normal tongue with white coating, no tremor, no deviation; pink gums, no swelling, no pyorrhea, no hemorrhage, no pigmentation, no lead line; regular teeth alignment, no dental caries, no missing tooth, no artificial tooth; tonsils are not swollen or congested, no excretion; pha

24、rynx is not congested or swollen, no excretion; normal pharyngeal reflex; normal voice, no hoarseness;Neck: No neck rigidity, no abnormal carotid artery pulsation, jugular vein is slightly distended, negative hepatojugular reflux, trachea is not deviated, thyroid gland is not enlarged;Chest: Symmetr

25、ical thoracic cage, barrel chest and bulge of interspaces are noted, no local protrusion or retraction, no abnormal pulsation, no tenderness; tachypnea and regular respiratory rhythm are noted; no varicose vein on chest wall.Lung:Inspection: Symmetrical, regular but weakened respiratory movement.Pal

26、pation: Symmetrical chest expansion, symmetrical but decreased tactile fremitus, no pleural friction rub, no subcutaneous tactile crepitus.Percussion: Hyperresonance over both lungs; inferior lung border is located at the level of 8th rib at the midclavicular line, at the level of the 10th rib at th

27、e midaxillary line and at the level of the 12th rib at the scapular line; diaphragmatic excursion equals 2cm.Auscultation: Diminished vesicular breath sound over both lungs, prolonged expiratory phase; bilateral diffuse wheezes; a few crackles over bilateral lung bases; no crepitant rale, no pleural

28、 friction rub; decreased vocal resonance.Heart:Inspection: Undetectable apical impulse, no precordial bulge and abnormal precordial pulsation.Palpation: Apical impulse is located in the left fifth interspace, 4cm medial from the midclavicular line, 1cm in diameter; no heaving apical impulse, no prec

29、ordial thrill, no pericardial friction frecmitus.Percussion: Decreased cardiac dullness; borders of cardiac dullness are indicated in the following table:Right (cm)InterspaceLeft (cm)Resonance on sternal line2ndThe right edge of the sternumResonance on sternal line3rd2Resonance on sternal line4th3.5

30、5th5.5The distance between the right midclavicular line and the anterior median line is 9cm.Auscultation: Heart rate is 90/min and regular; distant heart sounds are noted; no accentuation and splitting of the S1; S2 in the pulmonic valve area is accentuated and splitted; no S3 and S4 is heard; no pa

31、thologic murmur and pericardial friction rub.Blood vessels: No corrigan pulse (water-hammer pulse), no capillary pulsation, no pistol-shot sound, no abnormal arterial pulsation.Abdomen: Inspection: Flat abdomen without bulging, abdominal respiration is unremarkable; no rash, no pigmentation, no abdo

32、minal striae, no scar, normal distribution of hairs, no varicose vein, no peristalsis, no visible pulsation; umbilicus is not protruding, no secretion, no hernia.Palpation: Abdomen is soft, no mass is palpable; no direct tenderness or rebound tenderness, no fluid thrill, no succussion splash; the li

33、ver is palpable 2cm below the right costal margin, it is soft and smooth without tenderness, but has a dull edge; negative hepatojugular reflux sign; the gallbladder is not palpable, negative Murphy sign; spleen and kidneys are not palpable; no tenderness on costo-vertebral junction, costo-lumbar ju

34、nction, upper ureter point and mid-ureter point.Percussion: Tympany; liver dullness is not diminished, the upper border of the liver is at the 7th intercostal space in the right midclavicular line; no percussion pain is elicited on liver and kidneys; no shifting dullness.Auscultation: Normal perista

35、ltic sounds, 4/min; no gurgling, no abdominal bruit.Genitalia: Normal distribution of pubic hairs, normal development, no scar and ulcer.Anus and rectum: Not examined.Spine and extremities: No spinal deformity, no tenderness and percussion pain on spinous processes, normal spine mobility; No extremi

36、ty deformity, no pedal edema, no swelling, deformity, stiffness of joints, joint mobility is not restricted; no muscular atrophy, no muscular tenderness; no varicose veins of lower extremity; no clubbing of fingers and toes.Nervous system: Negative dermographism, normal abdominal reflex, normal bice

37、ps reflex, normal triceps reflex, normal knee jerk, normal Achilles jerk, negative Hoffmanns sign, negative Babinskis sign, negative Oppenheims sign, negative Gordons sign, negative Chaddocks sign, negative Kernigs sign, negative Brudzinskis sign.TESTS AND RESULTS:June, 7th blood exam: Hb 120g/L, RB

38、C 4.11012/L, WBC 9.3109/L, PLT 200109/L, eosinophil 0.14, band neutrocyte 0.05, segmented neutrocyte 0.60, lymphocyte 0.18, monocyte 0.02.June, 7th sputum exam: mucous sputum, Curschmanns spirals (+), Charcot-Leyden crystal protein (+), eosinophil (+).June, 7th CXR: hyperlucent lungs with flattened

39、diaphragm and widened interspaces.SUMMARY:The patient Li An, a 43-year-old male, was admitted on June 8th, 2007 because of Intermittent shortness of breath for 20 years and recurring attack for 1 week. He complained of recurrent shortness of breath over the past 20 years. Attacks often occured in th

40、e early morning or in cold weather and could be triggered by eating eggs. The symptom usually resolved in 10 minutes without treatment. The symptom had been aggravated since 10 years before. He reported recurrent shortness of breath accompanied by chest tightness, wheezing, cough, sneezing, itchy no

41、se and sweating. He was more comfortable in sitting position than in supine position during attacks and symptoms usually were relieved in a few hours after expectoration of frothy sputum. There had been nopalpitation, hemoptysis, pink frothy sputum and chest pain. He was quite normal between attacks

42、. He was diagnosed as “asthma”. Cimaterol could relieve the symptoms quickly. Since one week before he has been suffering from shortness of breath that could not be relieved by cimaterol. He had “scarlet fever” at the age of 11. He is a smoker. One of his younger brother has history of “asthma”.Phys

43、ical examination: BP: 143/87mmHg, T: 37, P: 90 /min, R: 30/min. The patient is normally developed and in moderate nutritional status. He is orthopneic and acutely ill-looking with flushing and slight cyanosis. He is conscious, hyperhidrotic with moist skin. There are no palpable lymph nodes. Remarka

44、ble flaring of nares and slightly distended jugular vein are noted. Trechea is not deviated. Thyroid gland is not enlarged. Chest and lung examination reveals symmetrical thoracic cage, barrel chest, bulge of interspaces, decreased tactile fremitus, hyperresonance over both lungs, descending inferio

45、r lung border, decreased diaphragmatic excursion, bilateral diffuse wheezes and a few crackles over bilateral lung bases. His heart rate is 90/min and regular. Cardiac examination is notable for decreased cardiac dullness, distant heart sounds, accentuated and splitted S2 in the pulmonic valve area.

46、 No cardiac murmur is heard. He has a soft and smooth liver with a dull edge which is palpable 2cm below the right costal margin. There is no liver tenderness. Hepatojugular reflux sign is negative.Tests and results: June, 7th blood exam: Hb 120g/L, RBC 4.11012/L, WBC 9.3109/L, PLT 200109/L, eosinop

47、hil 0.14, band neutrocyte 0.05, segmented neutrocyte 0.60, lymphocyte 0.18, monocyte 0.02.June, 7th sputum exam: mucous sputum, Curschmanns spirals (+), Charcot-Leyden crystal protein (+), eosinophil (+).June, 7th CXR: hyperlucent lungs with flattened diaphragm and widened interspaces.IMPRESSIONS:Br

48、onchial asthmaChronic obstructive pulmonary diseaseRecorder:_ADMISSION NOTEName: Xiaoling LiAddress: #11 Yanjiang East Road, GuangzhouSex: FemaleOccupation: HousewifeAge: 28Complainer of history: HerselfMarital status: MarriedSource and Reliability: Self-referred; seemsReliableRace: HanAdmission dat

49、a: 11:00AM. Nov. 12, 2006Nationality: ChinaRecord data: 13:00PM. Nov. 12, 2006CHIEF COMPLICANTS Palpitation with dyspnea for 5 months, and accompanied by edema of lower limbs for 20 days.PRESENT HISTORYThe patient was in good health until 5 months ago, when she began to experience palpitation with d

50、yspnea after normal walk for half hour or climbing 3 floors. The symptoms were relieved after having a rest. During recent 20 days, his palpitation with dyspnea, accompanied with edema of lower limbs, appeared after slight activities. The edema of lower limbs was aggravated in the afternoon and reli

51、eved in early morning. She has had no nocturnal paroxysmal dyspnea, hemoptysis, pharyngalgia, and fever. She sometimes coughed with small amounts of white sputum without pink bubble sputum. His urine volume of every day has been reduced to 400500 mL since lower limb edema appeared. She came to our h

52、ospital 3 days ago and was admitted because of “heart disease”. His appetite has been decreased and he has experienced poor sleep and abdominal distension in the past 20 days. Her body weight has no significant change. Stool has been normal. Now she is able to walk to the second floor.PAST HISTORY T

53、he patient was suffered from measles at the age of 3. She sometimes had pharyngalgia in recent 5 years. Her pharyngalgia occurred 4-5 times per year, lasted to 2-3 days per time and associated with low fever. No history of “tuberculosis and hepatitis”. No allergy to food and drugs. No history of sur

54、gry and trauma.Review of System:Respiratory system: No other history of repeatedly pharyngodynia, chronic cough, hemoptysis and chest pain except symptoms mentioned above.Circulatory system: See history of present illness above.Alimentary system: No history of regurgitation, hiccup, dysphagia, nause

55、a, vomiting, abdominal pain, constipation, diarrhea, hemotemesis, hemotochezia, and jaundice except abdominal distension mentioned above.Genitourinary system: No history of lumbago, frequent micturition, urgent micturition, odynuria, dysuresia, hemoturia, abnormal urine volume, facial edema, and gen

56、ital ulcer.Hematopoietic system: No history of tiredness，dizziness, dim eyesight, gum bleeding, rhinorrhagia, subcutaneous hemorrhage, lymph node enlargement, hepatomegalia, hypersplenotrophy, and ostalgia.Metabolic and Endocrine system: No history of abnormal appetite, cold intolerance, hidrosis, p

57、olydipsia, polyuria, hand tremor, psychologic changes, significant obesity, significant weight loss, hirsutism, trichomadesis, hyperpigmentation, and alteration of sexual function.Muscle, skeleton and joint system: Four years ago she was suffered from a migratory arthritis with red, swelling, warm a

58、nd pain in knee, ankle, wrist, elbow, and shoulder joints when the climate changed. This symptom had been recurrently attacked for 5 months and disappeared until aspirin was taken. Neural system: No history of dizziness, headache, vertigo, syncope, decreased memory, visual disorder, insomnia, conscious disturbance, jitter, convulsion, paralysis, and paresthesia.Mental status: No hallucination, delusion, disorientation, and abnormal feeling.PERSONAL HISTORYShe was born and