英文病历文章 mets考试英语作文写病历是什么时态
\u82f1\u6587\u75c5\u5386~~\u6025AN EXAMPLE OF MEDICAL CASE RECORD IN ENGLISH Patient 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\uff1aThe patient was born in Xi\u2019an 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 mather was well. Physical Examination\uff1aT.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 6thcostal 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 \uff08cm\uff09 Interspaces Left (cm) 1.5 \u2161 2.0 2.0 \u2162 4.0 3.0 \u2163 8.0 \u2164 10.0 \u2165 14.0 The distance from midsternal line to midclavicular line was 10cm. The heart rate was 96/min, regular. There was a grade \u2161soft 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\uff1a disease with degree\u2162 heart failure Signature \u00d7\u00d7\u00d7
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病例写作是医生日常的工作。接下来为大家整理英文病例写作范文，希望对你有帮助哦!Details个人资料
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。)
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。
RS呼吸系统
Dyspnea on exertion, particularly uphill, but not limiting; no cough sputum/wheeze
劳累时呼吸困难，上坡尤其如此，但无呼吸限制，无咳嗽咳痰、哮喘。
GIT gastrointestinal tract胃肠道
No current indigestion现无消化不良。
No symptoms lile previous duodenal ulcer过去无十二指肠溃疡症状。
No vomiting/dysphagia/abdominal pain无呕吐、吞咽困难、腹部疼痛。
GUS genitourinary system生殖泌尿道
No urinary systems无泌尿道症状。
NS神经系统
No headache/syncope无头痛、晕厥。
No dizziness/limb weakness/sensory loss无眩晕、肢体麻木、感觉丧失。
No disturberd bision/hearing/smell/speech无视觉、听力、味觉、嗅觉、语言障碍。
MS运动系统
No painful gout for 5 years无痛性痛风5年。
No joint pain/stiffness/swelling无关节痛、僵硬、肿胀。
No disability无伤残。
Skin皮肤
No rash/pruritus/bruising无皮疹、瘙痒、青肿。
Drug history药物史
Atenolol 100 mg once daily(Atenolol 100mg每天1次)
GTN as required需要服用硝酸甘油。
Not taking aspirin无服用过阿斯匹林。
Allergies: penicillin-skin rash过敏反应：青霉素――皮疹。
FH(family history)家族史
Father died of “heart attack” at age 53.
父亲53岁死于“心脏病”。
Mother died of old age at 76.
母亲于76岁去世。
SH(social history)社会史
Lives with wife who fit and well.妻子健在，与其共同生活。
Own house私宅。
Completely independent生活全部自理。
Smoking 20 cigs/day for many years多年每天抽烟20支。
Alcohol: 24 units per week饮酒：每周24个单位。
Sexual history: not appropriate性生活：未评价。
Overseas travel: not appropriate海外旅游：未评价。
Pets: not appropriate宠物：未评价。
Occupation: heavy goods vehicle driver职业：大型货车卡车司机。
O/E(on examination)体检结果
General 一般情况
Unwell, sweaty, clammy, no cyanosis/jaundice
一般情况不佳，出汗、皮肤湿冷，无青紫、黄疸。
temperature: 37.5℃
体温37.5℃。
cigarette-stained fingers
烟熏手指。
no arcus / xanthomas / xanthelasma
无老人弓环、黄瘤、黄斑瘤。
CVS心血管系统
Pluse 104 bpm regular, normal character
脉搏每分钟104次，规则，心音正常。
BP110/70 mmHg (right), 112/74 mmHg (left)
血压110/70 mmHg右，112/74 mmHg左。
JVP(jugular venous pulse) normal
颈静脉博动正常。
No precordial scars /chest deformities
无心前区疤痕、胸廓畸形。
Apex beat displaced to anterior axillary’s line 6th intercostals space
心尖博动向腋前线第6肋间移位。
No parasternal heave /thrills
无胸骨旁隆起、震颤。
Auscultation: heart sounds normal, but soft pan systolic murmur at apex radiating to axilla
听诊：心音正常，但心尖问及收缩前柔和杂音，向腋窝放射。
PSM at apex and ejection systolic murmur in aortic area with no radiation
心尖问及收缩前柔和杂音，以及主动脉区喷射性收缩期杂音，无放射。
ESM in aortic area
收缩期射血杂音。
Peripheral pulses: absent right popliteal to dorsails pedis
周围脉搏：右腘窝至足背动脉博动阙如。
No sacral or ankle edema
无骶部与踝部水肿。
RS呼吸系统
Trachea central 气管居中。
Respiratory rate15/ min, no respiratory distress呼吸频率15次/分，无呼吸窘迫。
Expansion symmetrical and normal胸廓扩张对称正常。
Vocal fremitus normal 语音震颤正常。
Percussion note normal叩击音正常。
Breath sounds vesicular throughout, no added sounds全肺闻及水泡音，无额外音。
Abdomen腹部
No scars/ veins distension无疤痕、静脉怒张。
Palpation: soft, but tender LIF(left iliac fossa)扪诊：腹部柔软，但有触痛(左髂前窝)。
Percussion note normal叩击音正常。
Auscultation: bowel sounds normal听诊：肠鸣音正常。
Genitalia not examined生殖器未检查。
Rectal examination: not performed肛门检查：未检查。
NS神经系统
Higher function normal高级神经功能正常。
Cranial nerves颅神经
ⅰ: normal第一对颅神经：正常。
ⅱ:PERRLA(pupils equal in reaction to light and accomodation)/ normal fundi and visual fields 第二对颅神经：瞳孔对光调节反应等大，正常眼底与视野。
ⅲ,ⅳ,Ⅵ: no diplopia / nystagmus第三、四、九颅神经：无复视和眼球震颤。
ⅴ-Ⅻ: normal第五至十二对颅神经正常。
upper and lower limbs: power, tone, coordination, sensation all normal
上下肢：肌力、肌张力、协调、感觉正常。
When love beckons to you, follow him, though his ways are hard and steep. And when
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