Составьте историю болезни на английском

Sure! Here is a detailed guide on how to create a case history (medical case record) in English. The structure below is typical for medical documentation and can be adapted depending on the purpose (e.g., academic, clinical practice, or case studies). Here's how to structure it:

Case History

1. Patient Information

• Name: [Full Name of the Patient]
• Age: [Age of the Patient]
• Gender: [Male/Female/Other]
• Date of Admission: [Date]
• ID Number: [Unique ID, if applicable]

2. Chief Complaint (CC)

• The main reason for the patient’s visit, stated in their own words.
• Example: "Severe chest pain lasting for three hours."

3. History of Present Illness (HPI)

• A detailed chronological account of the illness:
  • Onset: When did the symptoms start?
  • Location: Where is the symptom located? (e.g., left side of the chest)
  • Duration: How long do the symptoms last? (e.g., constant or intermittent)
  • Character: Describe the nature of the symptom (e.g., sharp, dull, throbbing).
  • Aggravating/Relieving Factors: What makes it worse or better?
  • Associated Symptoms: Any other symptoms that occur alongside the main complaint.

4. Past Medical History (PMH)

• Any relevant previous illnesses or conditions.
  • Chronic Diseases: Diabetes, hypertension, asthma, etc.
  • Surgeries: List any past surgical procedures.
  • Medications: Any ongoing medication or allergies.
  • Family History: Mention hereditary conditions like heart disease, cancer, etc.

5. Social History

• Lifestyle Information: Smoking, alcohol use, drug use, physical activity level.
• Occupation: Patient’s job and its potential health implications.
• Living Conditions: Urban/rural, exposure to pollution, housing.

6. Review of Systems (ROS)

A systematic checklist to identify symptoms the patient might not have mentioned:

• General: Weight changes, fatigue, fever.
• Cardiovascular: Chest pain, palpitations.
• Respiratory: Shortness of breath, cough.
• Gastrointestinal: Nausea, vomiting, abdominal pain.
• Neurological: Headache, dizziness, weakness.

7. Physical Examination

• General appearance: Conscious, alert, oriented.
• Vital Signs:
  • Temperature: [e.g., 98.6°F]
  • Heart Rate: [e.g., 72 bpm]
  • Blood Pressure: [e.g., 120/80 mmHg]
  • Respiratory Rate: [e.g., 16/min]
• Systematic Examination:
  • Cardiovascular: Heart sounds, murmurs.
  • Respiratory: Breath sounds, wheezing.
  • Abdomen: Tenderness, organ enlargement.
  • Neurological: Reflexes, coordination.

8. Laboratory and Diagnostic Tests

• Blood Work: CBC, blood glucose levels, cholesterol.
• Imaging: X-ray, CT, MRI, ultrasound.
• Specialized Tests: ECG, biopsy results, etc.

9. Diagnosis

• Provide the primary diagnosis based on the findings.
• Example: "Acute Myocardial Infarction (Heart Attack)."

10. Treatment Plan

• Medications: Names, dosages, and duration.
• Procedures: Any surgical or therapeutic interventions planned.
• Lifestyle Changes: Recommendations for diet, exercise, or habits.
• Follow-up: Schedule for subsequent visits or further tests.

11. Prognosis

• Expected outcome or course of the disease.
• Example: "With timely intervention, the prognosis is good."

12. Additional Notes

• Any other observations or relevant patient information.

Example Case History:

Name: John Doe
Age: 45
Gender: Male
Date of Admission: December 20, 2024

Chief Complaint:
"Severe chest pain radiating to the left arm for the past three hours."

History of Present Illness:
The patient experienced sudden onset of chest pain after moderate exertion. Pain is sharp, radiates to the left arm, and is accompanied by sweating and nausea. No previous episodes of this nature.

Past Medical History:

• Hypertension for 5 years.
• No known drug allergies.

Social History:
Smoker (15 cigarettes/day), no alcohol. Sedentary lifestyle.

Physical Examination:

• BP: 150/90 mmHg
• HR: 88 bpm
• Respiratory Rate: 18/min

Laboratory Tests:

• Elevated Troponin I.
• ECG: ST-segment elevation.

Diagnosis:
Acute Myocardial Infarction (STEMI).

Treatment Plan:

• Administer aspirin 300 mg.
• Perform primary PCI.
• Lifestyle counseling upon discharge.

Prognosis:
Favorable with prompt treatment.

This format ensures clarity and completeness, essential for medical documentation.