咳嗽病历书写范文合集

英文回答：

Cough is a common symptom that can be caused by various underlying conditions. When documenting a cough-related medical history, it is important to provide comprehensive and accurate information. Here is a sample template for writing a cough medical record:

Chief Complaint: The patient presents with a persistent cough.

History of Present Illness: The cough has been present for two weeks, and it is described as dry and non-productive. The patient denies any associated symptoms such as fever, chest pain, or shortness of breath.

Past Medical History: The patient has a history of asthma, which is well-controlled with an inhaler. There are no other significant medical conditions reported.

Medications: The patient currently takes an albuterol inhaler for asthma symptoms.

Allergies: No known drug allergies.

Social History: The patient is a non-smoker and denies any exposure to environmental irritants or allergens.

Family History: There is no family history of chronic respiratory conditions.

Physical Examination:

General: The patient appears well-nourished and in no acute distress.

Vital Signs: Blood pressure, heart rate, respiratory rate, and temperature are within normal limits.

Chest: Auscultation reveals clear breath sounds bilaterally with no adventitious sounds.

Assessment and Plan:

Based on the patient's history and physical examination findings, the likely diagnosis is an acute exacerbation of asthma. The plan includes:

1. Prescribe a short course of oral corticosteroids to reduce airway inflammation.

2. Advise the patient to continue using the albuterol inhaler as needed for symptom relief.

3. Provide education on asthma triggers and the importance of avoiding them.

4. Schedule a follow-up appointment in two weeks to assess the response to treatment.

中文回答：

咳嗽是一种常见的症状，可能由多种潜在疾病引起。在记录咳

嗽相关的病史时，提供全面准确的信息非常重要。以下是一份咳嗽病历书写的示例模板：

主诉，患者主诉持续咳嗽。

现病史，咳嗽已经持续两周，被描述为干咳，没有痰。患者否认有发热、胸痛或呼吸困难等相关症状。

既往病史，患者有哮喘病史，使用吸入器控制良好。没有其他重要的疾病史。

药物史，患者目前使用沙丁胺醇吸入器治疗哮喘症状。

过敏史，没有已知的药物过敏史。

社会史，患者不吸烟，否认接触环境刺激物或过敏原。

家族史，没有慢性呼吸系统疾病的家族史。

体格检查：

一般情况，患者营养良好，无急性痛苦。

生命体征，血压、心率、呼吸频率和体温均在正常范围内。

胸部，听诊双侧呼吸音清晰，无异常音。

评估和计划：

根据患者的病史和体格检查结果，初步诊断为哮喘急性加重。治疗计划包括：

1. 开具口服糖皮质激素短程疗程，以减少气道炎症。

2. 建议患者根据需要继续使用沙丁胺醇吸入器缓解症状。

3. 提供哮喘诱因的教育，以及避免接触诱因的重要性。

4. 安排两周后的复诊，以评估治疗效果。