How to Write a Case Report用英文写病例报告How to Write a Case Report用英文写病例报告
How to Write a Case Report
Yang x x, 30-year-old, male, teacher, was admitted to our hospital on November 1, 1990, because of pain in the right lower abdomen for two days.
On the morning, two days prior to his admission, t...
How to Write a Case Report用英文写病例报告
How to Write a Case Report
Yang x x, 30-year-old, male, teacher, was admitted to our hospital on November 1, 1990, because of pain in the right lower abdomen for two days.
On the morning, two days prior to his admission, the patient started having pain in upper abdomen. The pain gradually increased in severity and was accompanied with
nausea and vomiting, the vomitus being undigested food and acid fluid. He had a poor
appetite. About six hours later, the pain shifted and continuous with exacerbations at times. The patient described it as a prickly sensation and said it was intolerable. The patient went to a nearby hospital for treatment. He took some medicines but without any effect. The
pain become more intense early this morning. So he come to our hospital for emergency
treatment. Since the illness, he has had a slight fever, which ranges from 38?C to 38.5?C
and has normal urine. He has been constipated for three days.
Past history: In January 1989, he had similar abdominal pain for three days and the pain subsided after antibiotic treatment. No history of TB, hepatitis or other major
infectious disease.
Physical Examination(PE)
T: 38?C.P:90/min. R: 22/min. BP: 120/80 mmHg.
Well developed and nourished. Mentally clear but in acute distress. Head and sense organs normal. Sclera not jaundiced. Neck soft and freely moveable from side to side.
Trachea in midline. Thyroid not enlarged. Chest normal on inspection and symmetrical
with equal movement during respiration. Breathing sounds over both lungs clear. Heart
beat regular, with a rate of 90/min, and no murmurs heard. Abdomen examination
presented in the “Surgical condition” below. No deformity of disturbance of function in
spine and extremities. No pathological reflexes detected. Anus and external genitalia are normal.
Surgical Condition
Abdomen flat. Liver and spleen are not palpable below the costal margin. Marked
tenderness present in right lower quadrant, especially over Mcburney’s point, with rebound tenderness but no mass can be felt. Left lower abdomen soft and free from tenderness. No shifting dullness heard on percussion. Bowel sounds audible without high pitch.
Laboratory Findings:
WBC: 10,800 N:88% M: 10% E: 5%
Urine: Normal
Diagnosis:
杨XX, 30岁，已婚，男性，教师。右下腹疼痛两日，于1990年11月1日收住
我院治疗。
入院前两日，该病人在清晨感到上腹疼痛，此后疼痛逐渐加剧并伴有恶心呕吐，
呕吐物为未消化食物及胃酸。食欲不佳。6h后，疼痛转移至右下腹部并进行性加剧。
病人自诉有刺痛感，难以忍受。此后去附近医院诊治，服药无效。今晨疼痛更为剧
烈，于是来我院急诊。自发病起持续低热，体温38～38.5?C，小便正常。便秘三日。
既往病史：1989年1月患类似腹痛3d，抗生素治疗后疼痛消退，无肺结核、肝
炎或其他主要传染病病史。
体格检查：
体温38?C，脉搏90/分，呼吸20/分，血压120/80mmHg。
发育及营养状况良好，神志清醒但呈急性痛苦面容。头部及感觉器官正常，巩膜
无黄疸，颈部柔软，活动自如，气管居中，甲状腺无肿大，胸廓望诊正常，呼吸时
运动对称。两肺呼吸音清晰。心律齐，心率90/分，无杂音。腹部检查情况见以下“外
科情况”。脊柱及四肢无畸形或无功能异常。未见病理反射。肛门及外生殖器正常。
外科情况：
腹部扁平，肝脾肋下未及，右下腹部尤其麦氏点有明显压痛伴反跳痛。未触及肿
块。左下腹柔软无压痛。叩诊无移动性浊音。肠鸣音正常。
实验室检查结果
白细胞: 10,800 中性粒:88% 单核细胞: 10% 嗜酸性细胞: 5%
尿正常
诊断：
急性阑尾炎
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