Admission note：Personal details, admission date, major complaint, present history, simple previous and other histories, physical examination done, laboratory done, impression, problems, initial plan for treatment.
Present history : onset, cause or triggers, evolution, received treatment, general conditions after onset
Personal details, admission date, major complaint
A 25-year-old lady (個(gè)人資料) was admitted (被動(dòng)語(yǔ)態(tài)) to (was brought into) this hospital on May 11,2003 (入院日期) because of fever and caugh with chill for three days.
常用主訴：nausea, vomiting, diarrhea, cough, shot of breath, rash, bleeding, pain in some part (epigastium)， discomfort in some part (anal region), difficulty in some function (walking), loss of function (vision), decrease (increase) of function (libido), irregular in (menstrual period).
Present history
Four days ago ,the patient took a trip to Guangzhou on business(發(fā)病背景).
The next day (起病時(shí)間) she complained of chill and malaise (起病特征), and in the afternoon (演變時(shí)間) she began to cough and temperature went up to 38 ℃ (演變狀況).
Self administration of APC and Dicough had no effect (已診治情況).
The patient was in good nutritional and conscious condition on admission (起病當(dāng)初一般情況).
一般過去時(shí)，用簡(jiǎn)單句，介詞或名詞短語(yǔ)作時(shí)間狀語(yǔ)以體現(xiàn)病情演變。
“起病”常用動(dòng)詞：start, begin, appear, develop, be attacked with.
時(shí)間狀語(yǔ)：on the following day, yesterday morning, the next day, on September 16, 2003. at 6 pm.
已診治情況：be (un)responsive to, be (in)effective to.
Simple previous and other histories
The patient has been healthy and has no special disease previously including pneumococcal pneumonia and TB and family history.
現(xiàn)在完成時(shí)或一般過去時(shí)均可
常用時(shí)間狀語(yǔ)：before, prior to, previous to admission (entry, hospitalization).
家族史常用句型：There is no family history of allergy. There is no family numbers who had TB. Sb is living (fit and well). Sb died at 60 of hypertension.
Physical examination done
Body temperature (was) 38.4 ℃；respiration rate 30/min；pulse rate 104 b/min；BP 108/72 mmHg.
She was found to be slightly dyspnea. 醫(yī)學(xué)全.在線.網(wǎng).站.提供
The right lower posterior chest showed (也可用主動(dòng)態(tài)) dullness on percussion with moist rales at the end of inspiration on auscultation.
生命體征一般用省略句
反映體檢結(jié)果用被動(dòng)態(tài)；X線檢查用主動(dòng)態(tài)
句子均用一般過去時(shí)
常用句型：On examination sth was found. There were sth abnormal. Physical examination revealed that …
Inspection：sth was found to be
Palpation：there were sth (pain，mass)
Percussion：some organ show by… positive by percussion
Auscultation：show sth positive by auscultation
Laboratory done
X-ray films of the chest showed cloudy patches over both lower lungs in the posterior-anterior view and the lateral view.
The white blood cell count was 10.0×109/L(8 000/mm3)
And the blood has been sampled for liver function, kidney function, arterial gas analysis as well as PCR and bacterial culture.
Those lab reports haven’t arrived.
試驗(yàn)結(jié)果用“主系表”句型
以采樣、送樣或匯報(bào)均用現(xiàn)在完成時(shí)，常用被動(dòng)語(yǔ)態(tài)
常用動(dòng)詞：reveal, show, indicate.
檢查 of 器官 with 方法：CT scan of chest with pre- and post-contrast
Impression
Our impression of the case would be severe acute respiratory syndrome.
可用虛擬語(yǔ)氣，也可用陳述語(yǔ)氣
初步印象：the initial diagnosis.
Problems
On the day of admission, the patient was given anti-pyretic and ciprofloxacin.
Oxygen and CPAP have been applied (強(qiáng)調(diào)應(yīng)用至今)
However the patient’s temperature is still going on and dyspnea tends to be more severe.
入院治療用被動(dòng)態(tài)，一般過去時(shí)或現(xiàn)在完成時(shí) (was given；has been given)
當(dāng)前問題用一般現(xiàn)在時(shí)醫(yī)學(xué).全在.線www.med126.com
Initial plan for treatment
The patient will be given tracheostomy when necessary
And meanwhile the patient will be prednisolone if the patient develops the early sign of respiratory failure or infiltrate patch is over one third of the both lung fields.
診療計(jì)劃用一般將來時(shí)＋條件狀語(yǔ)從句。
