2024年4月10日发(作者：)

颈椎间盘突出病历书写范文

英文回答：

Title: Medical Record Writing Sample for Cervical Disc

Herniation.

Patient: John Smith.

Age: 45。

Gender: Male.

Chief Complaint:

I am experiencing severe neck pain with radiating pain

down my right arm. The pain has been persistent for the

past two weeks and is affecting my daily activities.

History of Present Illness:

I first noticed the neck pain after lifting heavy boxes

while helping a friend move. Initially, the pain was mild

and I thought it would go away on its own. However, it

gradually worsened and started radiating down my arm. The

pain is sharp and shooting, and it is exacerbated by

certain movements or positions, such as turning my head or

lifting heavy objects.

Past Medical History:

I have never experienced any neck problems before.

However, I do have a history of occasional lower back pain

due to a previous injury.

Physical Examination:

Upon physical examination, I have tenderness and

limited range of motion in my neck. There is also muscle

weakness in my right arm, particularly in the biceps and

triceps muscles. Sensation in my right arm is slightly

diminished compared to my left arm. Reflexes are intact.

Diagnostic Tests:

An MRI scan was performed, which revealed a C5-C6 disc

herniation. The herniated disc is compressing the adjacent

nerve root, causing the radiating arm pain.

Diagnosis:

Cervical Disc Herniation at C5-C6 level.

Treatment:

I have been prescribed a combination of pain

medications, including nonsteroidal anti-inflammatory drugs

(NSAIDs) and muscle relaxants, to alleviate the pain and

reduce inflammation. Physical therapy sessions have also

been recommended to improve neck strength and flexibility.

Surgery may be considered if conservative treatments fail

to provide relief.

Prognosis:

The prognosis for cervical disc herniation varies

depending on the severity of the condition and the

individual's response to treatment. With appropriate

medical intervention and lifestyle modifications, most

patients experience significant improvement in symptoms

within a few weeks to several months.

中文回答：

标题，颈椎间盘突出病历书写范文。

患者，John Smith.

年龄，45岁。

性别，男。

主诉：

我感到严重的颈部疼痛，并伴有放射性疼痛沿着我的右臂。这

种疼痛已经持续了两周，影响了我的日常生活。

现病史：

我在帮助朋友搬家时，举重过重后首次注意到颈部疼痛。最初，

疼痛很轻微，我以为它会自行消失。然而，它逐渐加重并开始向我

的手臂放射。疼痛是尖锐而刺痛的，特定的动作或姿势会加重疼痛，

例如转动头部或举重。

既往病史：

我以前从未出现过任何颈部问题。然而，我有过一次腰部受伤

引起的偶发性腰痛。

体格检查：

在体格检查中，我颈部有触痛和活动范围受限。我的右臂肌肉

力量较弱，尤其是肱二头肌和肱三头肌。与左臂相比，右臂的感觉

稍有减弱。反射正常。

诊断检查：

进行了磁共振成像（MRI）扫描，结果显示C5-C6椎间盘突出。

突出的椎间盘压迫了相邻的神经根，导致放射性臂痛。

诊断：

C5-C6水平的颈椎间盘突出。

治疗：

我被开了一种联合使用非甾体类抗炎药（NSAIDs）和肌肉松弛

剂的止痛药物，以缓解疼痛和减少炎症。还建议进行物理治疗，以

改善颈部力量和灵活性。如果保守治疗无法缓解症状，可能会考虑

手术。

预后：

颈椎间盘突出的预后因病情严重程度和个体对治疗的反应而异。

通过适当的医疗干预和生活方式改变，大多数患者在几周到几个月

内会有明显的症状改善。