中英文對照病例书写格式及参考病例.docVIP

Weekly Case From Family Medicine Residency Training Program ——Family Medicine Education and Training Center of ZJU Tuberculous pericarditis pleurisy 病名（Disease）： 病例来源（Case source）：Sir Run Run Shaw Hospital, School of Medicine, ZJU 病例记录及总结人（Case Recording and summarizing）：LIU Yan 记录日期（Recording date，YY/MM/DD）： 2010/07/10 项目Item English 中文 病人基本情况 基本情况 Patients situation A 69-year-old woman , admitted on March 12,2010 69岁，女性，于2010年3月12日入院 主诉 主诉 Chief complaint (c/o) Shortness of breath for more than 40 days 胸闷气急40余天 现病史 现病史Present illness (PI) The patient was admitted to our hospital because of recurrent fevers. She had been well until 40 days earlier, when chills, night sweats developed, without cough, sputum production, dyspnea and hemoptysis. She was admitted to a local hospital. Supportive treatment was begun and the symptoms improved(details not available) and she was sent home. A few days later, dyspnea after activities developed and gradually worsened. Increasing breathlessness on lying flat occured. She was admitted to the same hospital. A chest radicgraph obtained reportedly showed showed “bilateral pleural effusion”. A thoracentesis was performed afterwards. An intrathoracic drain tube was administered. CT scan of the chest on March 6 revealed moderate bilateral pleural effusion, partly compressed lungs and pericardial effusion The test of liver function showed ALT 134/UL, AST 85/UL. Antibiotics were prescribed, as well as medications for protecting the liver. However,the symptoms remained unchanged. The patient reported poor sleep, yet no loss of appetite and weight loss. (PS: no specific causes were identified during this hospitalization. The patient came back to our hospital again because of recurrent dyspnea after being discharged this time). 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（+），WBC 280/ul。予胸腔穿刺置管，2010-3-6日复查胸部CT示：