1、英文大病例写作示例撰写大病例是实习医师与住院医师的日常工作，也是上级医师作进一步诊断治疗的原始依据，国外的英文大病例并无统一格式，但是基本内容大致相仿。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 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
2、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、
3、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
4、-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。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
5、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
6、.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Pulse 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 precardial scars /chest defor
7、mities无心前区疤痕、胸廓畸形。Apex beat displaced to anterior axillarys 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，但心尖闻及收缩期柔和杂音，向腋窝放射。PSM at apex and ejection systolic murm
8、ur in aortic area with no radiation心尖闻及收缩期柔和杂音，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 dorsalis 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。Ex
9、pansion 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
10、 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: normal 第一对颅神经：正常。:PERRLA(pupils equal in reaction to light and accomodation)/ normal fundi and visual fields 第二对颅神经：瞳孔
11、对光调节反应等大，正常眼底与视野。,: no diplopia / nystagmus 第三、四、九颅神经：无复视和眼球震颤。-: 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。Reflexes 反射 Right 右 Left 左Biceps 二头肌 Supinator 旋后肌 Triceps 三头肌 Knee 膝盖 Ankle 踝 Plantar 跖 Joints and skin： Normal 关节与皮肤：正常。Summ
12、aryA 47-year-old male smoker with a family history and previous history of ischaemic heart disease, presents with s 4-month history of increasing exertional chest pain and a 4-hour history of persistent, severe pain at rest, which is unrelieved by GTN and associated with nausea, vomiting, and sweati
13、ng. On examination, he has a resting tachycardia and evidence of left ventricular dilatation with a displaced apex beat and possible secondary mitral regurgitation. The most likely diagnosis is acute myocardial infarction.47 岁男性，有吸烟史与缺血性心脏病的家族史与过去病史，近 4 个月胸骨后压痛渐重，今静息时出现持续严重疼痛 4 小时，硝酸甘油未能缓解，并伴有恶心、呕吐与大汗。体检发现有静息时心动过速与左心室扩大依据，心尖搏动偏移，可能有二尖瓣返流。可能性最大的诊断是急性心肌梗死。
