英文大病历.docx

英文大病历.docx

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英文大病历

CompleteMedicalHistory

Name:

ZhanghouSex:

male

Profession:

peasantAge:

31years

Nativeplace:

TianJinAddress:

chituvillagechitutowndonglidistricttianjin

Maritalstate:

marriedNationality:

Han

Dateofadmission:

February282003Dateofhistorytaking:

February282003

Narrator:

thepatientReliabilityofthehistory:

reliable

TheHistory

ChiefComplaint:

lumbagofor2yearswithweakness,numbnessinlowerlimbs,moresevere2months.

PresentIllness:

2yearsago,afterworking,thepatientalwaysfeltlumbago,sometimesreferredpainatthehipandlowerextremities,mainlyatthedorsaltheleftlowerlimbwasmoresevere.Atthesametimehefeltweakandnumbatlowerlimbs,alsomoresevereintheleftside.Nomuscleatrophy,noabnormalofstoolandurine.Notemperatureabnormalorcolorchangesinthelocalskin.Nonailsdamaged.Thenthepatientwenttothehospitalinhistown,andhadaX-rayexamination,shownhypertrophyinthelumbarvertebrae.,givensomedrugsforpain-control.Afterhavingsomedrugsandmorerest,thesymptomslightened.But2monthsago,withoutsignificantcauses,thesymptomsbecamemoresevere.Thelumbagooftenmadehimsleeplessatnights.Andhecanonlywalk500

meterswithoutabreak.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,polyuriadistributedchangeoftemperandintelligence.

Nervoussystem:

Noheadache,projectilevomiting.nosyncope,spasm,impairedvision,abnormalsensationormotion.Nochangeofpersonality.nomania,depressionorhallucination.

Motorsystem:

lumbagoandlimitationofmovementfor2years.weaknessandnumbnessatlowerlimbs,theleftmoresevere.Nospasm,atrophyorpalalysis.Nojointredswollen,hot,painorlimitationofmotion.Notraumaorfracture.

Personalhistory:

borninhernativeplaceandlivinginTianjin.Nohistoryofexposuretohabitsofdrinkingorsmoking.

MaritalHistory:

.Marriedat24yearsoldandhavingachild.thechildandhiswifebothhealth.

Familyhistory:

denyingthefamilyhistoryofanyhereditydiseases,orMD,CAD,hypertensionect.

PhysicalExamination

Temperature:

°Cpulserate:

72/minrespiratoryrate:

18/minbloodpressure:

130/80mmHg

Generalappearance:

normaldevelopmentandmediuminnourished,noabnormalconsciousness,goodcorporationinexamination.Freeposition.

Skinandmucousmembrane:

Nopallid,cyanosis,andjaundice.noabnormalpigmentationanddepigmentation.noerythmaannulare,petechiaandspider

angioma.Normalelasticityofskin,noedema.

Superficiallymphnodes:

noenlargementofthesuperficiallymphnodes.

Headanditsorgans:

Skull:

nodeformity,tendernessormass.Evenlydistributedhairwithblackcolorandshine.

Eyes:

nodropoutofeyebrowandnomadarosis,noswollenorprolapseofeyelids.Nopallor,granules,folliclespectechiaeofconjunctivae.transparentofcornea,nonebula,keratoleukoma,malacia,ulcerorvascularization.Noexophthalmosormotionsoftheeyeballsinanydirection.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.

Palpation:

apicalimpulseanditsareaasthatininspection.Regular,normalintensity.Nopericardialfrictionrubsorthrill.

Percussion:

relativecardiacdullnessshownasfollows:

Right（cm）

ICS

Left（cm）

2

Ⅱ

2

2

Ⅲ

4

3

Ⅳ

6

Ⅴ

7

Thedistancebetweentheleftmidclvicularlineandthemidsternallineis8cm.

Auscultation:

HR72/minwithregularrhythm,heartsoundsclearandintensive.nomurmursatanyauscultationareaofthevalvula.Nopericardicalfrictionsound.

Radialarteries:

pulserate85/min,withregularrhythm,equalinbothsides,normalintensity.

Perivascularsigns:

nocapillarypulsation,waterhammerpulse,pistol-shotsoundsandDuroziez’smurmur.nopulsedeficit,andpulsealternant.

Abdomen:

Inspection:

symmetry.Nobulgeabdomen,abdominaldistention.normalabdominalrespiration.Novisiblegastrointestinalwaves.Novaricosity,scar,petechiaattheabdominal

Skin.

Palpation:

soft,notendernessandreboundingtenderness,notightenedabdominalwall.Nopalpablemass.

Liver:

notpalpable.

Gallbladder:

notpalpable.Negativeofmurphy’ssign.

Kidneys:

notpalpable.Notendernessintheanysiteofkidneysorureters.

Spleen:

notpalpable.

Appendix:

notendernessattheMcburney’ssite.

Percussion:

tympanyinallovertheabdomen,noshiftingdullness.Nopercussivepainofliverandspleen.Theuppermarginofliveratthe5thICSintherightmidcalvicularline

Auscultation:

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.Normalotherplace.Biceps,triceps,radioperiosteal,andabdominalwallreflexeskneejerkandAchillesjerkactiver.babinski’s（+_）oppenheim’s,chaddock’s,gordon’snegative.Nopatellarorankleclonus.

Laboratoryfindings:

Bloodroutine:

WBC*10ª,N,L,Hb141g/l.RBC*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.noedemainthelowertensionofleftlowerlimbin4thgradeandrightlowerlimbin5-thgrade.Sensationinleftlowerlimbdecreased.Biceps,triceps,radioperiosteal,andabdominalwallreflexeskneejerkandAchillesjerkactiver.babinski’s（+_）oppenheim’s,chaddock’s,gordon’snegative.Nopatellaroranklesign（+）.

Summary

ThepatientnamedZhanghou,male,is31yearsold,admissionwiththechiefcomplaintof