《神经科英文病历语句ppt课件.ppt》由会员分享，可在线阅读，更多相关《神经科英文病历语句ppt课件.ppt（43页珍藏版）》请在三一办公上搜索。
1、神经科英文病历语句,杜万良北京天坛医院神经内科2011.2.25,1,前言,用简练的语言汇报主要的病史、发现、诊断、治疗。英语的习惯表达。照葫芦画瓢而已。,2,举例,颈“软”，实际是指“无抵抗感，易弯曲的”正确表达：The neck was supple错误表达：The neck was soft颈“强”，是指“不易弯的”正确表达：The neck was rigid,3,主诉,The patient is a year old female who presented（to）with（complaints of），accompanied by.the patient was admitted
2、 to with The patient is referred to foras well as She was unconscious for seconds,and was then confused for minutes.A 72-year-old man was admitted to because of,4,现病史,she developed in.She went to，received to treat her Two days prior to admission,he noted an abrupt onset of.he began having difficulty
3、（doing）when（doing）He had trouble（doing）,and subsequently in（doing）He then began to have problems（doing）have problems withgot worse with increasing in gradually increased up to and to a lesser extent involved his.,5,现病史,have worsened in the last monthshaving pain in radiating down to She was prescrib
4、ed the acute onset of which was more marked on（doing）,but was present to a lesser extent when（doing）.have continued to progress to the present time.was graded as The residual weakness on the left had completely resolved and he reported no new weakness.her continued to deteriorate.,6,现病史,her balance
5、deteriorated and on one occasion she fell in the shower.the became constant He saw an outside Neurologist who started him on（drugs）without improvement.,7,既往史,He has experienced The patient had a lengthy history of foryears treated with She has documented Within the past years,she has had year prior
6、to this presentation,she had an brief episode of She describes a year history of,but denies the patient underwent for ofPrevious medical history included Present medications include gives a negative history for smoking,drug,and only occasional alcohol use.,8,既往史,Family history includes a grandfather
7、 with Alzheimers diseaseThe patients mother died of Family history was positive for and（disease）in his father,negative for（disease）.Family history revealed no history of She is married with two childrenThe patient smoked packs a day in the past but quit completely years ago.He smoked one half pack o
8、f cigarettes per day for years,and he occasionally drank alcohol in moderation.does not smoke and is a social drinker.,9,既往史,His only medication was,325 mg which be began taking months ago.on medication for She had no known allergies.The patient was allergic to but could not remember the adverse rea
9、ction.She spent her early life in New Jersey and the past years in Houston.She lived with her boyfriend of four years and had no children.In addition to hypertension and COPD,the patient suffered from panic attacks.,10,生命征,BP：150/75 mmHg（150 over 75 millimetres of mercury,20 over 10 kilo pascal）Temp
10、erature 98;Respiration 16;Blood Pressure 114/60 and Pulse 86 while lying;Blood Pressure 110/60 and Pulse 94 while standing.The patient had a temperature of 37.5C,blood pressure of 115/45 to 180/80 mm Hg,pulse of 90 to 120/min,and respiratory rate of 16/min with 99%oxygen saturation on ambient（/room）
11、air.The oxygen saturation was 83 percent while the patient breathed ambient air and rose to 88 percent when 35 percent oxygen was administered by face mask.,11,生命征,The temperature was 37.7C,the pulse was 100,and the respirations were 19.The blood pressure was 140/60 mm Hg.The blood pressure was 120/
12、84 mm Hg,the pulse 80 beats per minute,and the temperature 37.2C.she was mildly febrile.she was afebrile.,12,内科查体,She weighed 80 kg(176 lb).Findings on a general examination were unremarkable.The lungs were clear on auscultation.The chest(/Lungs are)clear to auscultation and percussion without rales
13、,rhonchi,or wheezes.,13,内科查体,The heart shows(/had)a regular rate and rhythm without(/with no)rubs,gallops,or murmurs.The patients heart rate was regular,tachycardic with 2/6 systolic flow murmur,and he had no carotid bruits.The peripheral pulses are all within normal limits.A grade 1 systolic murmur
14、 was present at the cardiac apex.,14,内科查体,Her abdomen was soft and nontender.Bowel sounds are present and within normal limits.There is no tenderness to palpation and no masses are felt.There is no hepatosplenomegaly.The abdomen was distended,and there was evidence of ascites.A surgical scar was pre
15、sent over the right lower quadrant.The liver edge descended 3.5 cm below the right costal margin;the spleen was not felt.There was pitting(+)edema of the right leg to the knee.,15,神经科查体,On neurologic examination,Normal on was intact.was grossly unaffected.Physical examination was within normal limit
16、s with no evidence of His score on the National Institutes of Health Stroke Scale(NIHSS)(which ranges from 0 to 34,with higher scores indicating greater deficits)was 20.she appeared well.,16,Mental status,The patient was alert，fully oriented to person,place,time,and situation，and able to converse.he
17、 was found confused and poorly responsive on the floor of his hotel bathroom by his mother.The patient was awake,alert,and dysphasic.His speech is fluent without paraphasic errors.Speaks fluently speech shows frank dysarthria including labial,lingual and guttural consonants;,17,Mental status,He was
18、cooperative He resisted examination of the oropharynx.The neurologic examination showed a normal mental status,fluent speech,and mild dysarthria.,18,Cranial nerve function,Examination of the cranial nerves revealed the following:Olfaction was normal,as were the optic fundi and visual fields.The opti
19、c disks were not seen.The cranial-nerve examination revealed full visual fields with no extinction;Pupils are 3mm,equal,round,and reactive to light.The right pupil was 3 mm and unreactive to light;left pupil was 2 mm and sluggishly reactive to light.Extraocular movements intact without nystagmus,dis
20、conjugate gaze or ptosis Extraocular movements full in all directions of gaze.,19,Cranial nerve function,Mild limitation of eye abduction on both sides,more prominent on the right.There was slight gaze evoked nystagmus.Decreased sensation in the second and third divisions of the trigeminal nerve on
21、the left,to all modalities;Strong eye closures and equal grimaces Left sided facial droop with sparing of forehead.the strength of the sternocleidomastoid was weaker on the left side.Weber does not lateralize and air conduction is greater than bone conduction bilaterally.,20,Cranial nerve function,T
22、he palate elevates in the midline.There is a normal gag.The tongue protrudes in the midline without atrophy or fibrillations.The tongue deviated to the right.,21,Motor examination,Strength was 5/5 in all muscle groups.Muscle strength was difficult to assess as the patient was uncooperative.Strength
23、in the lower extremities was not assessed due to poor cooperation.Muscle strength was 5/5 throughout including neck flexors and extensors.her muscle strength was graded 3 to 4 on a scale of 5 proximally and 0 to 2 distally.Motor power was 5/5 in all the muscle groups except the right wrist extensors
24、,in which it was 4/5.,22,Motor examination,Normal bulk of muscles,without atrophy,hypertrophy or fasciculations.There was normal muscle bulk and tone,with full strength in both arms and legs.Increased tone in lower extremity muscles.Tone was slightly increased on the left side.Tone was normal in upp
25、er and lower extremities.The left arm and leg were weak,with motor power graded as follows:deltoids,biceps,and triceps,4/5;wrist extensors,3/5;wrist flexors,4/5;finger extensors,1/5;finger flexors,4/5;interossei,0/5;and iliopsoas,4/5.There was no pronator drift of the outstretched arms.,23,Reflexes,
26、Negative Babinski and Hoffman;mildly positive jaw jerk.Babinski and Hoffman not present.The deep-tendon reflexes were+and symmetric;an equivocal Babinski sign was elicited in the left foot.A few beats of clonus were noted at the left ankleThe deep-tendon reflexes were hyperactive.Hoffmans reflex(+)w
27、as elicited;there were two beats of clonus at the right ankle and five to seven beats at the left ankle.There was no clonus,but a left Babinski reflex was present.There were 13 beats of clonus in the right ankle and 12 beats in the left ankle;the left Babinski reflex persisted.the plantar responses
28、were flexor.,24,Sensory Examination,There was significant impairment of position sense bilaterally in the upper extremities to the elbow and in the lower extremities up to and including the knees.He had slight diminution to pinprick,light touch,and temperature in a glove-and-stocking distribution.Vi
29、bration was markedly decreased in the lower extremities below the knees.decreased sensation to pinprick and touch to midthigh regions bilaterally The patient responded equally to painful stimuli in all 4 extremities.Intact to pinprick,temperature,vibration,proprioception.,25,Sensory Examination,Ther
30、e is a sensory level at T6-7 for T/PP/LT.Below the T10 level,the sensation of a light touch and the sense of positionwere reduced to 30 percen,26,coordination,The patient had a slow,wide-based gait,was unable to walk on heels or toes,and could not perform tandem gait.He had a positive Romberg test.I
31、ntact in upper extremities on finger-to-nose with no dysmetria or dysdiadochokinesia.Gait was steady with good heel and toe walking.Arm swing normal.Tandem intact.Stance was wide-based and unsteady;The patient was unable to walk with a tandem gait and had a tendency to deviate to the left on walking
32、.,27,coordination,She was unable to keep her balance while sitting unsupported,and she was unable to stand on her own.She had mild clumsiness in her left arm and leg when performing finger tapping and on heel-to-shin testing.,28,Meningeal irritation,The neck was rigid,and Kernigs sign was present.,2
33、9,神经影像,PA view of left internal carotid artery(ICA)injection demonstrates occlusion of the distal M1 segment of the middle cerebral artery(MCA).A cranial MRI scan showed an enhancing mass,approximately 1.5 by 1.2by 1.0 cm,in the right cerebellar hemisphere,with deviation of the fourth ventricle;the
34、mass appeared to invade the right tentorium.A second mass,8 mm in diameter,was adjacent to the left frontal horn of the ventricle,and a third lesion,11 mm in its greatest dimension,was evident in the right corona radiata.MRI revealed abnormal increased signal in the middle cerebral distribution on t
35、he right without enhancement.,30,影像检查,Subarachnoid hemorrhage with a small amount of blood present in the occipital horns of the lateral ventricles.Moderate hydrocephalus is also present.3 to 4 mm aneurysm of the C-3 segment of the right internal carotid artery.Hypodense lesion seen on CT examinatio
36、n.Region of edema and abnormal signal in the right insula and right temporal lobe.an imaging study done revealed a C5/6 disc bulge A CT scan of the head without contrast was done approximately 10 hours after the initial symptoms.,31,影像检查,A MRI of the brain w on T2-weighted images the mass was surrou
37、nded by an area of hyperintensity,a finding consistent with edema.There was a mass effect,with effacement of right hemispheric sulci,partial effacement of the right lateral ventricle,a midline shift of approximately 8 mm,and slight right-sided uncal herniation.,32,影像检查,Ultrasonographic examination o
38、f the right and left carotid arteries showed minimal disease in the arterial bifurcations.A transcranial Doppler study showed normal flow in the distal internal carotid arteries and in the cerebral artery stems.,33,化验检查,White blood cell count,Hematocrit,Platelets,Sodium,Potassium,Chloride,Carbon dio
39、xide,Blood urea nitrogen,Creatinine,Glucose,Prothrombin time,Partial thromboplastin timethe prothrombin and partial-thromboplastin times were normal.The levels of magnesium,phosphorus,serum aspartate aminotransferase,serum alanine aminotransferase,and fibrinogen were normal.The hypercoagulability pr
40、ofile returned,showing a urine culture yielded a growth of vancomycin-resistant enterococci.,34,化验检查,The white-cell count was 7000 per cubic millimeter,with 82 percent neutrophils,13 percent lymphocytes,4 percent monocytes,and 1 percent eosinophils;the platelet count was 308,000 per cubic millimeter
41、,and the mean corpuscular volume 88 m3;The hematocrit was 36.2 percent;The phosphorus level was 2.1 mg per deciliter(0.68 mmol per liter).,35,lumbar puncture,A lumbar puncture revealed a WBC of 31 with a differential of 6%neutrophils,82%lymphocytes,and all CSF cultures negative.His parents deferred
42、lumbar puncture to confirm the diagnosis because of concerns over the possibility of complications resulting from increased intracranial pressure.,36,lumbar puncture,A lumbar puncture yielded clear,colorless cerebrospinal fluid that contained 540 red cells and1 white cell per cubic millimeter in the
43、 fourth tube.A stained smear contained 37 percent neutrophils,53 percent lymphocytes,7 percent monocytes,and3 percent nonhematic cells.The glucose level was 63 mg per deciliter(3.5 mmol per liter),and the total protein level 35 mg per deciliter.,37,其它,Electrocardiogram revealed sinus tachycardia wit
44、hout ischemic changes.Nerve conduction studies found multiple,predominantly axonal,mononeuropathies of motor and sensory nerves,including the right sural,left peroneal,left median,bilateral ulnar,and left radial nerves Ultrasound demonstrated a clot in the internal jugular,subclavian,axillary,and ce
45、phalic veins in the region of the PICC line.She underwent a skin biopsy to look for evidence of vascular or infectious changes.,38,Questions to be Addressed in Evaluating Patients with a Neurologic Illness,Was the onset of symptoms acute(e.g.,over days to weeks),subacute(e.g.,over a couple of months
46、),or chronic(e.g.,over several months or years)?What is the course of the illness(e.g.,monophasic,relapsingremitting,or progressive)?What was the pattern of involvement(e.g.,symmetric or asymmetric)at onset,and what is it at present?What are the associated symptoms and signs(e.g.,motor,sensory,or au
47、tonomic nervous system involvement)?What associated medical conditions are present,including medication use and history of toxic exposures?Is this a hereditary or acquired disorder?,39,诊断,he was diagnosed with was diagnosed as The final diagnosis was cerebral vein thrombosis with acute hemorrhagic i
48、nfarction presenting with seizure and persistent aphasia.,40,治疗,a peripherally inserted central catheter(PICC)line was placed.the patient was intubated and sedated for combativeness the patient was weaned off sedation and extubated without difficulty.A subarachnoid screw was placed for intracranial
49、pressure monitoring The patient was evaluated for infection and empirically treated with ciprofloxacin and metronidazole but without benefit.,41,治疗,The interventional neuroradiology department was consulted about the possibility of performing clot lysis in the event that the patient deteriorated cli
50、nically.The patient received aztreonam and vancomycin for possible meningitis from the subarachnoid screw,and he defervesed.she discontinued diethylcarbamazine citrate because of headache,nausea,and dizziness.The patient was given oxygen by face mask.Because of the patients hepatic disease,no antico
