英语医疗文件(2)：会诊记录
发布于 2010-07-19 · 浏览 3916 · IP 浙江浙江
这个帖子发布于 14 年零 297 天前，其中的信息可能已发生改变或有所发展。
belb咏歌 已点赞这篇会诊记录写得很详实，中规中矩，与国内的习惯很不同。
DATE OF CONSULTATION: 月/日/年
REQUESTING PHYSICIAN: John Doe, MD（在英语国家中一般用John Doe代表无名氏，类似中文的某某人）
REASON FOR CONSULTATION: Renal colic.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who has a history of kidney stones. He presented with a 5-day history of severe left flank and groin pain. It is associated with severe nausea and vomiting. Basically, the patient has not been able to keep anything down. He denies any fever. He had significant urgency and frequency at the time. He also had noticed some slowing and hesitancy in his urinary stream.
PAST MEDICAL HISTORY: Positive for hypertension, high cholesterol, history of kidney stones and back problems.
PAST SURGICAL HISTORY: Back surgery x2.
MEDICATIONS ON ADMISSION: Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin.
ALLERGIES: IVP DYE.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illegal substance abuse.
REVIEW OF SYSTEMS: No fever or chills. No headaches or seizure disorders. No shortness of breath or wheezing. No chest pains or palpitations. No heart problems. Positive for hypertension and high cholesterol. Severe nausea and vomiting with renal colic, otherwise none. GU, see above. The patient has a history of back problems. No arthralgia.
PHYSICAL EXAMINATION: Vital Signs: Review of the vital signs show that his temperature is 98.6 degrees, pulse is 94 per minute, respirations are 20 per minute and blood pressure is 164/101. General: The patient currently is in no apparent distress. He is alert and oriented x3. He is well nourished, well developed, cooperative, not anxious or agitated. He states that he got one injection of pain medication, and since that time, he has been completely pain-free and feels much better. Head and Neck: Head is normocephalic and atraumatic. Neck is supple. Trachea is midline. No JVD noted. Lungs: Respirations are unlabored. No audible wheezing or rhonchi. Abdomen: Soft, nondistended and nontender. No abnormal masses. No CVA tenderness on either side. Extremities: Full range of motion x4. No obvious focal neurological deficits noted.
LABORATORY DATA: The laboratory results are reviewed. Urinalysis shows specific gravity of 1.024, pH of 5.1, trace albumin and 2+ blood. Microscopic shows 0-3 rbc's, 0-4 wbc's and 1+ bacteria. CBC shows WBC of 28,700, hemoglobin of 17.5, hematocrit of 50.7 and platelet count of 232,000. Differential shows 77% neutrophils. Comprehensive metabolic panel shows essentially normal electrolytes, BUN 38 and creatinine 2.5. Liver functions normal. CT scan shows a 2-3 mm calculus at the left ureterovesical junction causing minimal hydronephrosis and hydroureter.
IMPRESSION AND RECOMMENDATIONS:
Left renal colic due to a passable stone.
The patient has now acutely become pain-free suggestive of possible stone passage.
The patient has a creatinine of 2.8, very likely due to dehydration because the patient has had severe nausea and vomiting over the last 5 days. The patient has severely elevated white blood cell count, but he states that he has been on steroids fairly recently. His baseline white blood cell count 2 months ago was 9000. His baseline creatinine was 1.3. Recommendation at this time is to continue monitoring the patient. It appears that he may have passed the stone. Rehydrate the patient. I will continue to closely monitor the patient with you.
Thank you for this consultation. If there are any questions, please do not hesitate to contact me.
DATE OF CONSULTATION: 月/日/年
REQUESTING PHYSICIAN: John Doe, MD（在英语国家中一般用John Doe代表无名氏，类似中文的某某人）
REASON FOR CONSULTATION: Renal colic.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who has a history of kidney stones. He presented with a 5-day history of severe left flank and groin pain. It is associated with severe nausea and vomiting. Basically, the patient has not been able to keep anything down. He denies any fever. He had significant urgency and frequency at the time. He also had noticed some slowing and hesitancy in his urinary stream.
PAST MEDICAL HISTORY: Positive for hypertension, high cholesterol, history of kidney stones and back problems.
PAST SURGICAL HISTORY: Back surgery x2.
MEDICATIONS ON ADMISSION: Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin.
ALLERGIES: IVP DYE.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illegal substance abuse.
REVIEW OF SYSTEMS: No fever or chills. No headaches or seizure disorders. No shortness of breath or wheezing. No chest pains or palpitations. No heart problems. Positive for hypertension and high cholesterol. Severe nausea and vomiting with renal colic, otherwise none. GU, see above. The patient has a history of back problems. No arthralgia.
PHYSICAL EXAMINATION: Vital Signs: Review of the vital signs show that his temperature is 98.6 degrees, pulse is 94 per minute, respirations are 20 per minute and blood pressure is 164/101. General: The patient currently is in no apparent distress. He is alert and oriented x3. He is well nourished, well developed, cooperative, not anxious or agitated. He states that he got one injection of pain medication, and since that time, he has been completely pain-free and feels much better. Head and Neck: Head is normocephalic and atraumatic. Neck is supple. Trachea is midline. No JVD noted. Lungs: Respirations are unlabored. No audible wheezing or rhonchi. Abdomen: Soft, nondistended and nontender. No abnormal masses. No CVA tenderness on either side. Extremities: Full range of motion x4. No obvious focal neurological deficits noted.
LABORATORY DATA: The laboratory results are reviewed. Urinalysis shows specific gravity of 1.024, pH of 5.1, trace albumin and 2+ blood. Microscopic shows 0-3 rbc's, 0-4 wbc's and 1+ bacteria. CBC shows WBC of 28,700, hemoglobin of 17.5, hematocrit of 50.7 and platelet count of 232,000. Differential shows 77% neutrophils. Comprehensive metabolic panel shows essentially normal electrolytes, BUN 38 and creatinine 2.5. Liver functions normal. CT scan shows a 2-3 mm calculus at the left ureterovesical junction causing minimal hydronephrosis and hydroureter.
IMPRESSION AND RECOMMENDATIONS:
Left renal colic due to a passable stone.
The patient has now acutely become pain-free suggestive of possible stone passage.
The patient has a creatinine of 2.8, very likely due to dehydration because the patient has had severe nausea and vomiting over the last 5 days. The patient has severely elevated white blood cell count, but he states that he has been on steroids fairly recently. His baseline white blood cell count 2 months ago was 9000. His baseline creatinine was 1.3. Recommendation at this time is to continue monitoring the patient. It appears that he may have passed the stone. Rehydrate the patient. I will continue to closely monitor the patient with you.
Thank you for this consultation. If there are any questions, please do not hesitate to contact me.
最后编辑于 2022-10-09 · 浏览 3916
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