中英文对照病例书写格式及参考病例

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1、WeeklyCaseFromFamilyMedicineResidencyTrainingProgram——FamilyMedicineEducationandTrainingCenterofZJUTuberculouspericarditis&pleurisy病名（Disease）：病例来源（Casesource）：SirRunRunShawHospital,SchoolofMedicine,ZJU病例记录及总结人（CaseRecordingandsummarizing）：LIUYan记录日期（Recordingdate，YY/MM/DD）：2010/07/10项目ItemEngli

2、sh中文病人基本情况基本情况Patient'ssituationA69-year-oldwoman,admittedonMarch12,201069岁，女性，于2010年3月12日入院主诉主诉Chiefcomplaint(c/o)Shortnessofbreathformorethan40days胸闷气急40余天现病史现病史Presentillness(PI)Thepatientwasadmittedtoourhospitalbecauseofrecurrentfevers.Shehadbeenwelluntil40daysearlier,whenchills,nightsweatsd

3、eveloped,withoutcough,sputumproduction,dyspneaandhemoptysis.Shewasadmittedtoalocalhospital.Supportivetreatmentwasbegunandthesymptomsimproved(detailsnotavailable)andshewassenthome.Afewdayslater,dyspneaafteractivitiesdevelopedandgraduallyworsened.Increasingbreathlessnessonlyingflatoccured.Shewasad

4、mittedtothesamehospital.Achestradicgraphobtainedreportedlyshowedshowed“bilateralpleuraleffusion”.Athoracentesiswasperformedafterwards.Anintrathoracicdraintubewasadministered.CTscanofthechestonMarch6revealed"moderatebilateralpleuraleffusion,partlycompressedlungsandpericardialeffusion"Thetestofliv

5、erfunctionshowedALT134/UL,AST85/UL.Antibioticswereprescribed,aswellasmedicationsforprotectingtheliver.However,thesymptomsremainedunchanged.患者40余天前无明显诱因出现每日下午高热，最高体温39度，伴寒战，偶有夜间盗汗，无咳嗽咳痰，无呼吸困难，无胸痛咯血。于当地医院就诊，予支持对症治疗后好转（具体不详）。之后患者开始出现活动后呼吸困难，逐渐加重，夜间不能平卧，需高枕卧位，至当地医院就诊，发现“双侧胸腔积液”，予胸腔穿刺抽液检查示：李凡他试验（+），W

6、BC280/ul。予胸腔穿刺置管，2010-3-6日复查胸部CT示：两侧胸腔中等量积液，部分肺组织膨胀不全，心包积液。两中下肺斑片索条影，纵膈淋巴结影。ALT134U/L,AST85U/L。予左氧氟沙星依替米星等抗炎治疗,甘利欣护肝，患者上述症状无明显缓解，今为进一步诊治遂来我院就诊。门诊以“胸腔积液”收入院。自病以来，神清精神可，胃纳佳，睡眠差，二便无殊，体重无明显减轻。（附注：病人本次住院期间未明确病因，出院后因“再发胸闷气急”入我院）。Thepatientreportedpoorsleep,yetnolossofappetiteandweightloss.(PS:nospecif

7、iccauseswereidentifiedduringthishospitalization.Thepatientcamebacktoourhospitalagainbecauseofrecurrentdyspneaafterbeingdischargedthistime).、既往史高血压病8年，服用珍菊降压片，未监测血压。喹诺酮类药物过敏。社会史SocialHistory(SH)Nospecialsocialhistory.无殊。家庭史Fa