《物理診斷學(xué)》 英文病歷示例（中文稿）

患者，李華，男，69歲，退休教師，因心悸一年，加重5個(gè)月于1989年6月6日入院。

一年前患者健康。1988年5月感到輕微心悸，在工作勞累，快走及上樓時(shí)感氣短，傍晚下肢浮腫，休息后則減輕。近5個(gè)月來，心悸氣短明顯加重。以致不能行走，亦不能平臥，不得不坐著度過整夜，有時(shí)咳嗽，咳少量白色粘液，無血。患者無寒戰(zhàn)、發(fā)熱、胸痛或關(guān)節(jié)疼痛，排尿正常。

系統(tǒng)復(fù)習(xí)無特殊，1949年曾患“大葉肺炎”，無藥物過敏史。

個(gè)人史：生在西安，曾去過中國(guó)南方，但無疫水接觸史，抽煙一天10支，1945年結(jié)婚，其妻健康，有一女孩亦健康，其父死于胃癌，其母健在。

查體：體溫36.8℃，脈搏90次/分，呼吸28次/分，BP23.5/13.3kPa，發(fā)育良好，營(yíng)養(yǎng)中等，體胖、半臥位，顏面蒼白，全身浮腫，神智清楚，查體合作。皮膚無紅斑、黃疸、紫瘢。淋巴結(jié)未觸及。頭部、眼、鼻、耳、口正常，但口唇紫紺。頸軟，頸靜脈無充盈，甲狀腺未觸及，無細(xì)震顫或搏動(dòng)，氣管正中。胸廓兩側(cè)對(duì)稱，呼吸動(dòng)度對(duì)稱，無異常濁音區(qū)，但在兩肺底部可聞一些濕羅音。心尖搏動(dòng)所見，觸診時(shí)在第5肋間，距正中線14cm處，無細(xì)震顫，心濁音界如圖：

心率90次/分，律齊，心尖部可聞Ⅱ級(jí)柔和的吹風(fēng)樣收縮期雜音，P2＞A2，無胸膜磨擦音，腹軟，無壓痛及反跳痛，肝可觸及，在肋下2cm，輕度壓痛，脾未觸及；無移動(dòng)性濁音，其他正常。

正中線至左鎖骨中線距離10cm

初步診斷：

1.高血壓心臟病

2.Ⅲ度心衰

AN EXAMPLE OF MEDICAL CASE RECORDIN ENGLISH

Patient Li Hua,mate,69 years old,a retired teacher, was admitted on June 6,1989,because of palpitation for oneyear and becoming worse in recent 5 months.

The patient was quite well untilone year before May,1988, He felt slight palpitation and dyspnia during hardwork, fast walk , or climbing stairs, There was swelling of legs in the eveningbut he felt better after having a rest. In recent 5months, palpitation anddyspnia became so serious that he could neither walk nor lie down.He had to situp 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. Theurinating was normal.

There was nothing else abnormalin the case history review except a cured lobor pneumonia in 1949. He had nohistory of drug allergy.

Personal history：Thepatient was born in Xi’an in 1923. He had been to the south of China but didnot contact contaminated water. He smoked a bout 10 cigarettes daily. He got marriedin 1945. His wife was healthy .They had a daughter who was also healthy. Hisfather died of stomach cancer.His mather was well.

Physical Examination：T.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, waslying in bed with a semifallous position. He looked pale and suffered fromgeneral edima. He was mentally normal and cooperative in the examination.Therewas no eruption, no jaundice, no purpura on the skin, and the lymphnodes werenot palpable. The head, eyes, nose, ears, mouth were normal while the lips werecyanotic. The neck was soft, there was no venous engorgement. Thyroid glandswere not palpable, there were no thrill or brunt. The trachea was in midline.The chest and respiratory movements were symmetrical. There was no abnormaldullness 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 the6thcostal interspace, 14cm form the middle line, there was no thrill. Thecardiac dullness, 14cm from the middle line, there was no thrill. The cardiacdullness were as follows;

The distance from midsternal lineto midclavicular line was 10cm. The heart rate was 96/min, regular. There was agrade Ⅱsoft blowinglike systolic murmurat the apex,P2>A2,but no pericardium friction sound was heard. Abdominal wall was soft withouttenderness. The liver was palpable 2cm below the costal margin with slighttenderness. The spleen was not palpable and there was no shifting dull ness.The rest was normal.

Impression：

disease with

degreeⅢ heart failure

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