神經(jīng)科英文病歷語句課件

神經(jīng)科英文病歷語句杜萬良北京天壇醫(yī)院神經(jīng)內(nèi)科2011.2.251神經(jīng)科英文病歷語句杜萬良1前言用簡練的語言匯報主要的病史、發(fā)現(xiàn)、診斷、治療。英語的習慣表達。照葫蘆畫瓢而已。2前言用簡練的語言匯報主要的病史、發(fā)現(xiàn)、診斷、治療。2舉例頸“軟”，實際是指“無抵抗感，易彎曲的”正確表達：Theneckwassupple錯誤表達：Theneckwassoft頸“強”，是指“不易彎的”正確表達：Theneckwasrigid3舉例頸“軟”，實際是指“無抵抗感，易彎曲的”3主訴Thepatientisa……yearoldfemalewhopresented（to……）with（complaintsof）……，accompaniedby…….thepatientwasadmittedto……with……Thepatientisreferredto……for……aswellas……Shewasunconsciousfor……seconds,andwasthenconfusedfor……minutes.A72-year-oldmanwasadmittedto……becauseof……4主訴Thepatientisa……yearold現(xiàn)病史shedeveloped……in…….Shewentto……，received……totreather……Twodayspriortoadmission,henotedanabruptonsetof…….hebeganhavingdifficulty……（doing）when……（doing）Hehadtrouble……（doing）,andsubsequentlyin……（doing）Hethenbegantohaveproblems……（doing）haveproblemswith……gotworsewithincreasing…………in……graduallyincreasedupto……andtoalesserextentinvolvedhis…….5現(xiàn)病史shedeveloped……in…….5現(xiàn)病史……h(huán)aveworsenedinthelast……monthshavingpainin……radiatingdownto……Shewasprescribed……theacuteonsetof……whichwasmoremarkedon……（doing）,butwaspresenttoalesserextentwhen……（doing）.……h(huán)avecontinuedtoprogresstothepresenttime.wasgradedas……Theresidualweaknessonthelefthadcompletelyresolvedandhereportednonewweakness.her……continuedtodeteriorate.6現(xiàn)病史……h(huán)aveworsenedinthelas現(xiàn)病史herbalancedeterioratedandononeoccasionshefellintheshower.the……becameconstantHesawanoutsideNeurologistwhostartedhimon……（drugs）withoutimprovement.

7現(xiàn)病史herbalancedeterioratedan既往史Hehasexperienced……Thepatienthadalengthyhistoryof……for……yearstreatedwith……Shehasdocumented……Withinthepast……years,shehashad…………yearpriortothispresentation,shehadanbriefepisodeof……Shedescribesa……yearhistoryof……,butdenies……thepatientunderwent……for……of……Previousmedicalhistoryincluded……Presentmedicationsinclude……givesanegativehistoryforsmoking,drug,andonlyoccasionalalcoholuse.8既往史Hehasexperienced……8既往史FamilyhistoryincludesagrandfatherwithAlzheimer'sdiseaseThepatientsmotherdiedof……Familyhistorywaspositivefor……and……（disease）inhisfather,negativefor……（disease）.Familyhistoryrevealednohistoryof……SheismarriedwithtwochildrenThepatientsmoked……packsadayinthepastbutquitcompletely……yearsago.Hesmokedonehalfpackofcigarettesperdayfor……years,andheoccasionallydrankalcoholinmoderation.doesnotsmokeandisasocialdrinker.9既往史Familyhistoryincludesag既往史Hisonlymedicationwas……,325mgwhichbebegantaking……monthsago.onmedicationfor……Shehadnoknownallergies.Thepatientwasallergicto……butcouldnotremembertheadversereaction.ShespentherearlylifeinNewJerseyandthepast……yearsinHouston.Shelivedwithherboyfriendoffouryearsandhadnochildren.InadditiontohypertensionandCOPD,thepatientsufferedfrompanicattacks.

10既往史Hisonlymedicationwas……,生命征BP：150/75mmHg（150over75millimetresofmercury,20over10kilopascal）Temperature98;Respiration16;BloodPressure114/60andPulse86whilelying;BloodPressure110/60andPulse94whilestanding.Thepatienthadatemperatureof37.5°C,bloodpressureof115/45to180/80mmHg,pulseof90to120/min,andrespiratoryrateof16/minwith99%oxygensaturationonambient（/room）air.Theoxygensaturationwas83percentwhilethepatientbreathedambientairandroseto88percentwhen35percentoxygenwasadministeredbyfacemask.11生命征BP：150/75mmHg（150over75生命征Thetemperaturewas37.7°C,thepulsewas100,andtherespirationswere19.Thebloodpressurewas140/60mmHg.Thebloodpressurewas120/84mmHg,thepulse80beatsperminute,andthetemperature37.2°C.shewasmildlyfebrile.shewasafebrile.12生命征Thetemperaturewas37.7°C,內(nèi)科查體Sheweighed80kg(176lb).Findingsonageneralexaminationwereunremarkable.Thelungswereclearonauscultation.Thechest(/Lungsare)cleartoauscultationandpercussionwithoutrales,rhonchi,orwheezes.

13內(nèi)科查體Sheweighed80kg(176lb)內(nèi)科查體Theheartshows(/had)aregularrateandrhythmwithout(/withno)rubs,gallops,ormurmurs.Thepatient'sheartratewasregular,tachycardicwith2/6systolicflowmurmur,andhehadnocarotidbruits.Theperipheralpulsesareallwithinnormallimits.Agrade1systolicmurmurwaspresentatthecardiacapex.14內(nèi)科查體Theheartshows(/had)are內(nèi)科查體Herabdomenwassoftandnontender.Bowelsoundsarepresentandwithinnormallimits.Thereisnotendernesstopalpationandnomassesarefelt.Thereisnohepatosplenomegaly.Theabdomenwasdistended,andtherewasevidenceofascites.Asurgicalscarwaspresentovertherightlowerquadrant.Theliveredgedescended3.5cmbelowtherightcostalmargin;thespleenwasnotfelt.Therewaspitting(++)edemaoftherightlegtotheknee.15內(nèi)科查體Herabdomenwassoftandn神經(jīng)科查體Onneurologicexamination,……Normalon…………wasintact.……wasgrosslyunaffected.Physicalexaminationwaswithinnormallimitswithnoevidenceof……HisscoreontheNationalInstitutesofHealthStrokeScale(NIHSS)(whichrangesfrom0to34,withhigherscoresindicatinggreaterdeficits)was20.sheappearedwell.16神經(jīng)科查體OnneurologicexaminationMentalstatus

Thepatientwasalert，fullyorientedtoperson,place,time,andsituation，andabletoconverse.hewasfoundconfusedandpoorlyresponsiveonthefloorofhishotelbathroombyhismother.Thepatientwasawake,alert,anddysphasic.Hisspeechisfluentwithoutparaphasicerrors.Speaksfluentlyspeechshowsfrankdysarthriaincludinglabial,lingualandgutturalconsonants;17MentalstatusThepatientwasMentalstatusHewascooperativeHeresistedexaminationoftheoropharynx.Theneurologicexaminationshowedanormalmentalstatus,fluentspeech,andmilddysarthria.18MentalstatusHewascooperativCranialnervefunction

Examinationofthecranialnervesrevealedthefollowing:Olfactionwasnormal,asweretheopticfundiandvisualfields.Theopticdiskswerenotseen.Thecranial-nerveexaminationrevealedfullvisualfieldswithnoextinction;Pupilsare3mm,equal,round,andreactivetolight.Therightpupilwas3mmandunreactivetolight;leftpupilwas2mmandsluggishlyreactivetolight.Extraocularmovementsintactwithoutnystagmus,disconjugategazeorptosisExtraocularmovementsfullinalldirectionsofgaze.19CranialnervefunctionExaminaCranialnervefunctionMildlimitationofeyeabductiononbothsides,moreprominentontheright.Therewasslightgazeevokednystagmus.Decreasedsensationinthesecondandthirddivisionsofthetrigeminalnerveontheleft,toallmodalities;StrongeyeclosuresandequalgrimacesLeftsidedfacialdroopwithsparingofforehead.thestrengthofthesternocleidomastoidwasweakerontheleftside.Weberdoesnotlateralizeandairconductionisgreaterthanboneconductionbilaterally.20CranialnervefunctionMildlimCranialnervefunctionThepalateelevatesinthemidline.Thereisanormalgag.Thetongueprotrudesinthemidlinewithoutatrophyorfibrillations.Thetonguedeviatedtotheright.21CranialnervefunctionThepalaMotorexamination

Strengthwas5/5inallmusclegroups.Musclestrengthwasdifficulttoassessasthepatientwasuncooperative.Strengthinthelowerextremitieswasnotassessedduetopoorcooperation.Musclestrengthwas5/5throughoutincludingneckflexorsandextensors.hermusclestrengthwasgraded3to4onascaleof5proximallyand0to2distally.Motorpowerwas5/5inallthemusclegroupsexcepttherightwristextensors,inwhichitwas4/5.22MotorexaminationStrengthwasMotorexaminationNormalbulkofmuscles,withoutatrophy,hypertrophyorfasciculations.Therewasnormalmusclebulkandtone,withfullstrengthinbotharmsandlegs.Increasedtoneinlowerextremitymuscles.Tonewasslightlyincreasedontheleftside.Tonewasnormalinupperandlowerextremities.Theleftarmandlegwereweak,withmotorpowergradedasfollows:deltoids,biceps,andtriceps,4/5;wristextensors,3/5;wristflexors,4/5;fingerextensors,1/5;fingerflexors,4/5;interossei,0/5;andiliopsoas,4/5.Therewasnopronatordriftoftheoutstretchedarms.23MotorexaminationNormalbulkoReflexes

NegativeBabinskiandHoffman;mildlypositivejawjerk.BabinskiandHoffmannotpresent.Thedeep-tendonreflexeswere++andsymmetric;anequivocalBabinskisignwaselicitedintheleftfoot.AfewbeatsofclonuswerenotedattheleftankleThedeep-tendonreflexeswerehyperactive.Hoffman’sreflex(+)waselicited;thereweretwobeatsofclonusattherightankleandfivetosevenbeatsattheleftankle.Therewasnoclonus,butaleftBabinskireflexwaspresent.Therewere13beatsofclonusintherightankleand12beatsintheleftankle;theleftBabinskireflexpersisted.theplantarresponseswereflexor.24ReflexesNegativeBabinskiandSensoryExamination

Therewassignificantimpairmentofpositionsensebilaterallyintheupperextremitiestotheelbowandinthelowerextremitiesuptoandincludingtheknees.Hehadslightdiminutiontopinprick,lighttouch,andtemperatureinaglove-and-stockingdistribution.Vibrationwasmarkedlydecreasedinthelowerextremitiesbelowtheknees.decreasedsensationtopinprickandtouchtomidthighregionsbilaterallyThepatientrespondedequallytopainfulstimuliinall4extremities.Intacttopinprick,temperature,vibration,proprioception.25SensoryExaminationTherewasSensoryExaminationThereisasensorylevelatT6-7forT/PP/LT.BelowtheT10level,thesensationofalighttouchandthesenseofpositionwerereducedto30percen26SensoryExaminationThereisacoordination

Thepatienthadaslow,wide-basedgait,wasunabletowalkonheelsortoes,andcouldnotperformtandemgait.HehadapositiveRombergtest.Intactinupperextremitiesonfinger-to-nosewithnodysmetriaordysdiadochokinesia.Gaitwassteadywithgoodheelandtoewalking.Armswingnormal.Tandemintact.Stancewaswide-basedandunsteady;Thepatientwasunabletowalkwithatandemgaitandhadatendencytodeviatetotheleftonwalking.27coordinationThepatienthadacoordinationShewasunabletokeepherbalancewhilesittingunsupported,andshewasunabletostandonherown.Shehadmildclumsinessinherleftarmandlegwhenperformingfingertappingandonheel-to-shintesting.28coordinationShewasunabletoMeningealirritationTheneckwasrigid,andKernig’ssignwaspresent.29MeningealirritationTheneckw神經(jīng)影像PAviewofleftinternalcarotidartery(ICA)injectiondemonstratesocclusionofthedistalM1segmentofthemiddlecerebralartery(MCA).AcranialMRIscanshowedanenhancingmass,approximately1.5by1.2by1.0cm,intherightcerebellarhemisphere,withdeviationofthefourthventricle;themassappearedtoinvadetherighttentorium.Asecondmass,8mmindiameter,wasadjacenttotheleftfrontalhornoftheventricle,andathirdlesion,11mminitsgreatestdimension,wasevidentintherightcoronaradiata.MRIrevealedabnormalincreasedsignalinthemiddlecerebraldistributionontherightwithoutenhancement.30神經(jīng)影像PAviewofleftinternalc影像檢查Subarachnoidhemorrhagewithasmallamountofbloodpresentintheoccipitalhornsofthelateralventricles.Moderatehydrocephalusisalsopresent.3to4mmaneurysmoftheC-3segmentoftherightinternalcarotidartery.HypodenselesionseenonCTexamination.Regionofedemaandabnormalsignalintherightinsulaandrighttemporallobe.animagingstudydonerevealedaC5/6discbulgeACTscanoftheheadwithoutcontrastwasdoneapproximately10hoursaftertheinitialsymptoms.31影像檢查Subarachnoidhemorrhagewi影像檢查AMRIofthebrainw&w/ocontrastandaMRAwasperformedthreedaysfollowingadmission.SerialcoronalT1-weightedMRIshowingclottedbloodingwithinthelefttransversesinus.Amagneticresonanceimaging(MRI)studyofthebraindisclosedamass,3.7by2.5by2.9cm,intherightlentiformnucleus;onT2-weightedimagesthemasswassurroundedbyanareaofhyperintensity,afindingconsistentwithedema.Therewasamasseffect,witheffacementofrighthemisphericsulci,partialeffacementoftherightlateralventricle,amidlineshiftofapproximately8mm,andslightright-sideduncalherniation.32影像檢查AMRIofthebrainw&w/o影像檢查Ultrasonographicexaminationoftherightandleftcarotidarteriesshowedminimaldiseaseinthearterialbifurcations.AtranscranialDopplerstudyshowednormalflowinthedistalinternalcarotidarteriesandinthecerebralarterystems.33影像檢查Ultrasonographicexaminati化驗檢查Whitebloodcellcount,Hematocrit,Platelets,Sodium,Potassium,Chloride,Carbondioxide,Bloodureanitrogen,Creatinine,Glucose,Prothrombintime,Partialthromboplastintimetheprothrombinandpartial-thromboplastintimeswerenormal.Thelevelsofmagnesium,phosphorus,serumaspartateaminotransferase,serumalanineaminotransferase,andfibrinogenwerenormal.Thehypercoagulabilityprofilereturned,showing……aurinecultureyieldedagrowthofvancomycin-resistantenterococci.34化驗檢查Whitebloodcellcount,He化驗檢查Thewhite-cellcountwas7000percubicmillimeter,with82percentneutrophils,13percentlymphocytes,4percentmonocytes,and1percenteosinophils;theplateletcountwas308,000percubicmillimeter,andthemeancorpuscularvolume88μm3;Thehematocritwas36.2percent;Thephosphoruslevelwas2.1mgperdeciliter(0.68mmolperliter).35化驗檢查Thewhite-cellcountwas7lumbarpunctureAlumbarpuncturerevealedaWBCof31withadifferentialof6%neutrophils,82%lymphocytes,&11%monocytes;RBC10;protein27;glucose67;andallCSFculturesnegative.Hisparentsdeferredlumbarpuncturetoconfirmthediagnosisbecauseofconcernsoverthepossibilityofcomplicationsresultingfromincreasedintracranialpressure.36lumbarpunctureAlumbarpunctulumbarpunctureAlumbarpunctureyieldedclear,colorlesscerebrospinalfluidthatcontained540redcellsand1whitecellpercubicmillimeterinthefourthtube.Astainedsmearcontained37percentneutrophils,53percentlymphocytes,7percentmonocytes,and3percentnonhematiccells.Theglucoselevelwas63mgperdeciliter(3.5mmolperliter),andthetotalproteinlevel35mgperdeciliter.37lumbarpunctureAlumbarpunctu其它Electrocardiogramrevealedsinustachycardiawithoutischemicchanges.Nerveconductionstudiesfoundmultiple,predominantlyaxonal,mononeuropathiesofmotorandsensorynerves,includingtherightsural,leftperoneal,leftmedian,bilateralulnar,andleftradialnervesUltrasounddemonstratedaclotintheinternaljugular,subclavian,axillary,andcephalicveinsintheregionofthePICCline.

Sheunderwentaskinbiopsytolookforevidenceofvascularorinfectiouschanges.38其它ElectrocardiogramrevealedsQuestionstobeAddressedinEvaluatingPatientswithaNeurologicIllness

Wastheonsetofsymptomsacute(e.g.,overdaystoweeks),subacute(e.g.,overacoupleofmonths),orchronic(e.g.,overseveralmonthsoryears)?Whatisthecourseoftheillness(e.g.,monophasic,relapsing–remitting,or

progressive)?Whatwa