我们选择的这一系列英文病历一般包括Chief complaint（主诉）、Past medical history（过往病史）、Examination（医院检查）、Clinical course（临床过程）和Case follow-up（复查情况）几个部分。
R. F., a 42-year-old woman, has been complaining of atypical headaches for the past few weeks. She experienced vomiting with one of the headaches that she could not attribute to the flu or something she had eaten. She does not have a history of migraines. R. F. had an appointment with a neurologist, who referred her to the neurosurgery clinic for evaluation of a possible cerebral hemorrhage.
Patient is a 42-YO female c/o sudden and severe headaches over the past three to four weeks; one headache was accompanied with vomiting. Patient admits to recent photophobia and intermittent blurred vision. She has a history of venous thrombi following an emergency hip surgery for a fracture she suffered two years ago when she was in an automobile accident. Multiple vertebrae and her pelvis were also fractured. No other complications postaccident noted. Hypertensive with a BP of 154/86; neurological and physical examination is otherwise normal. Diagnoses: cerebral aneurysm and hypertension.
The neurologist ordered a CT scan that revealed a small saccular aneurysm measuring 4 mm near the circle of Willis, the arterial pathway supplying the brain. R. F. was scheduled for a craniotomy and surgical insertion of a clip around the neck of the aneurysm to control bleeding and offer protection from rebleeding.
R. F. underwent a craniotomy in which a special clip was placed around the neck of the aneurysm. She was closely observed for postoperative neurolocial deficits, including vascular spasm, a serious possible complication. She tolerated the procedure well with no complications.
R. F. 接受了开颅手术，并于动脉瘤颈置入了专用夹。术后接受了神经功能损伤方面的严密观察，包括可能出现的严重神经痉挛。术后观察结果正常，未见并发症。