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 (个人资料) was admitted (被动语态) to (was brought into) this hospital on May 11,2003 (入院日期) because of fever and caugh with chill for three days.
常用主诉：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(发病背景).
The next day (起病时间) she complained of chill and malaise (起病特征), and in the afternoon (演变时间) she began to cough and temperature went up to 38 ℃ (演变状况).
Self administration of APC and Dicough had no effect (已诊治情况).
The patient was in good nutritional and conscious condition on admission (起病当初一般情况).
一般过去时，用简单句，介词或名词短语作时间状语以体现病情演变。
“起病”常用动词：start, begin, appear, develop, be attacked with.
时间状语：on the following day, yesterday morning, the next day, on September 16, 2003. at 6 pm.
已诊治情况：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.
现在完成时或一般过去时均可
常用时间状语：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. 医学全.在线.网.站.提供
The right lower posterior chest showed (也可用主动态) dullness on percussion with moist rales at the end of inspiration on auscultation.
生命体征一般用省略句
反映体检结果用被动态；X线检查用主动态
句子均用一般过去时
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.
试验结果用“主系表”句型
以采样、送样或汇报均用现在完成时，常用被动语态
常用动词：reveal, show, indicate.
检查 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.
可用虚拟语气，也可用陈述语气
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 (强调应用至今)
However the patient’s temperature is still going on and dyspnea tends to be more severe.
入院治疗用被动态，一般过去时或现在完成时 (was given；has been given)
当前问题用一般现在时医学.全在.线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.
诊疗计划用一般将来时＋条件状语从句。
