10.神经科英文病历语句

神经科英文病历语句杜万良北京天坛医院神经内科2011.2.251前言用简练的语言汇报主要的病史、发现、诊断、治疗。英语的习惯表达。照葫芦画瓢而已。2举例颈“软”，实际是指“无抵抗感，易弯曲的”正确表达：Theneckwassupple错误表达：Theneckwassoft颈“强”，是指“不易弯的”正确表达：Theneckwasrigid3主诉Thepatientisa……yearoldfemalewhopresented（to……）with（complaintsof）……，accompaniedby…….thepatientwasadmittedto……with……Thepatientisreferredto……for……aswellas……Shewasunconsciousfor……seconds,andwasthenconfusedfor……minutes.A72-year-oldmanwasadmittedto……becauseof……4现病史shedeveloped……in…….Shewentto……，received……totreather……Twodayspriortoadmission,henotedanabruptonsetof…….hebeganhavingdifficulty……（doing）when……（doing）Hehadtrouble……（doing）,andsubsequentlyin……（doing）Hethenbegantohaveproblems……（doing）haveproblemswith……gotworsewithincreasing…………in……graduallyincreasedupto……andtoalesserextentinvolvedhis…….5现病史……haveworsenedinthelast……monthshavingpainin……radiatingdownto……Shewasprescribed……theacuteonsetof……whichwasmoremarkedon……（doing）,butwaspresenttoalesserextentwhen……（doing）.……havecontinuedtoprogresstothepresenttime.wasgradedas……Theresidualweaknessonthelefthadcompletelyresolvedandhereportednonewweakness.her……continuedtodeteriorate.6现病史herbalancedeterioratedandononeoccasionshefellintheshower.the……becameconstantHesawanoutsideNeurologistwhostartedhimon……（drugs）withoutimprovement.7既往史Hehasexperienced……Thepatienthadalengthyhistoryof……for……yearstreatedwith……Shehasdocumented……Withinthepast……years,shehashad…………yearpriortothispresentation,shehadanbriefepisodeof……Shedescribesa……yearhistoryof……,butdenies……thepatientunderwent……for……of……Previousmedicalhistoryincluded……Presentmedicationsinclude……givesanegativehistoryforsmoking,drug,andonlyoccasionalalcoholuse.8既往史FamilyhistoryincludesagrandfatherwithAlzheimer'sdiseaseThepatientsmotherdiedof……Familyhistorywaspositivefor……and……（disease）inhisfather,negativefor……（disease）.Familyhistoryrevealednohistoryof……SheismarriedwithtwochildrenThepatientsmoked……packsadayinthepastbutquitcompletely……yearsago.Hesmokedonehalfpackofcigarettesperdayfor……years,andheoccasionallydrankalcoholinmoderation.doesnotsmokeandisasocialdrinker.9既往史Hisonlymedicationwas……,325mgwhichbebegantaking……monthsago.onmedicationfor……Shehadnoknownallergies.Thepatientwasallergicto……butcouldnotremembertheadversereaction.ShespentherearlylifeinNewJerseyandthepast……yearsinHouston.Shelivedwithherboyfriendoffouryearsandhadnochildren.InadditiontohypertensionandCOPD,thepatientsufferedfrompanicattacks.10生命征BP：150/75mmHg（150over75millimetresofmercury,20over10kilopascal）Temperature98;Respiration16;BloodPressure114/60andPulse86whilelying;BloodPressure110/60andPulse94whilestanding.Thepatienthadatemperatureof37.5°C,bloodpressureof115/45to180/80mmHg,pulseof90to120/min,andrespiratoryrateof16/minwith99%oxygensaturationonambient（/room）air.Theoxygensaturationwas83percentwhilethepatientbreathedambientairandroseto88percentwhen35percentoxygenwasadministeredbyfacemask.11生命征Thetemperaturewas37.7°C,thepulsewas100,andtherespirationswere19.Thebloodpressurewas140/60mmHg.Thebloodpressurewas120/84mmHg,thepulse80beatsperminute,andthetemperature37.2°C.shewasmildlyfebrile.shewasafebrile.12内科查体Sheweighed80kg(176lb).Findingsonageneralexaminationwereunremarkable.Thelungswereclearonauscultation.Thechest(/Lungsare)cleartoauscultationandpercussionwithoutrales,rhonchi,orwheezes.13内科查体Theheartshows(/had)aregularrateandrhythmwithout(/withno)rubs,gallops,ormurmurs.Thepatient'sheartratewasregular,tachycardicwith2/6systolicflowmurmur,andhehadnocarotidbruits.Theperipheralpulsesareallwithinnormallimits.Agrade1systolicmurmurwaspresentatthecardiacapex.14内科查体Herabdomenwassoftandnontender.Bowelsoundsarepresentandwithinnormallimits.Thereisnotendernesstopalpationandnomassesarefelt.Thereisnohepatosplenomegaly.Theabdomenwasdistended,andtherewasevidenceofascites.Asurgicalscarwaspresentovertherightlowerquadrant.Theliveredgedescended3.5cmbelowtherightcostalmargin;thespleenwasnotfelt.Therewaspitting(++)edemaoftherightlegtotheknee.15神经科查体Onneurologicexamination,……Normalon…………wasintact.……wasgrosslyunaffected.Physicalexaminationwaswithinnormallimitswithnoevidenceof……HisscoreontheNationalInstitutesofHealthStrokeScale(NIHSS)(whichrangesfrom0to34,withhigherscoresindicatinggreaterdeficits)was20.sheappearedwell.16MentalstatusThepatientwasalert，fullyorientedtoperson,place,time,andsituation，andabletoconverse.hewasfoundconfusedandpoorlyresponsiveonthefloorofhishotelbathroombyhismother.Thepatientwasawake,alert,anddysphasic.Hisspeechisfluentwithoutparaphasicerrors.Speaksfluentlyspeechshowsfrankdysarthriaincludinglabial,lingualandgutturalconsonants;17MentalstatusHewascooperativeHeresistedexaminationoftheoropharynx.Theneurologicexaminationshowedanormalmentalstatus,fluentspeech,andmilddysarthria.18CranialnervefunctionExaminationofthecranialnervesrevealedthefollowing:Olfactionwasnormal,asweretheopticfundiandvisualfields.Theopticdiskswerenotseen.Thecranial-nerveexaminationrevealedfullvisualfieldswithnoextinction;Pupilsare3mm,equal,round,andreac