英文病例表达模板

Content•Historytaking•Physicalexamination•PatientnotewritingIntroductionHowcanIhelpyoutoday?Whatbroughtyoutothehospital/clinictoday?Whatareyourconcerns?ChestpainOnset开始时间Precipitatingfactors诱因Duration持续时间Relievingfactors缓解因素Frequency发作频率Associatedsymptoms伴随症状Previousepisodes既往发作Progression进展InterviewapatientwithchestpainHello,Mr.Jones,IamDr.Zhuang,it’snicetomeetyou.HowcanIhelpyoutoday?Doyouhavepain?Whendiditstart?Howlonghaveyouhadthispain?Howoftendoesitcomeon?Wheredoyoufeelthepain?Canyoushowmeexactlywhereitis?Doesthepaintravelanywhere?•Whatisthepainlike,canyoudescribeitforme?•Isitsharp,dull,burning,pulsating,cramping,orpressure-like?•Isitconstant,ordoesitcomeandgo?•Onascaleof1to10,with10beingtheworstpainofyourlife,howwouldyourateyourpain?•Whatbringsthepainon？•Doesanythingmakethepainbetter?•Doesanythingmakeitworse?•Haveyouhadsimilarpainbefore?Associatedsymptoms:Nausea恶心Vomiting呕吐Cough,phlegm咳嗽，咳痰Shortnessofbreath呼吸困难Headache头疼Dizziness,roomspinningaroundyou,light-headed眩晕Passout,blackout,loseconsciousness,syncope晕厥Heartspeeding,palpitation心慌Briefphysicalexam:whattosaybeforeandduringtheexamIneedtolistentoyourheart/lungsnowCanyouholdyourbreath,please?Canyoutakeadeepbreathforme,please?Canyousit,please?Canyouturntoyourleftside,please?Iamgoingtoexamineyourlegstocheckfluidretention,isthatokaywithyou?IneedtocheckthepulseinyourarmandlegsnowPatientnoteVS:vitalsignsWNL:withinnormallimitsChest:nontender,lungscleartoA&P(auscultationandpercussion),Auscultation:decreasedbreathsounds[L/R]Abnormalsounds:wheeze,rub,rale[L/R][base/midlung/apex]CV:cardiovascularS1,S2WNLRegularrate&rhythm,RRRNorub/gallops/murmursittingandsupine(noRGM)NoJVD(jugularvenousdistention)PMInotdisplaced(pointofmaximalimpulse)Noclubbing,edemaCarotid,radial,DP(dorsipedis),pulseNL&equalB/Labsent/decreased/NL/boundingNocarotidbruitsCaseJosephShort,a46-year-oldmale,comestoEDcomplainingofchestpainHPI:Historyofpresentillness46yoMc/ochestpain.Thepainstarted40minutesbeforehepresentedtoEDwithasteady7/10pressuresensationinthemiddleofhischestthatradiatedtotheleftarmandtheneck.Nothingmakesitworseorbetter.Nausea,sweatinganddyspneaarealsopresent.Similarepisodeshaveoccurredduringthepast3months.Theseepisodeswereprecipitatedbywalkingupthestairs,strenuousworkandheavymeals.Painduringtheseepisodeswaslesssevere,lasted5-10minutes,anddisappearedspontaneouslyoraftertakingantacids.PhysicalexaminationPatientisinseverepainBP165/85mmHg(botharms)RR22/minuteNeck:noJVD,nobruits.Chest:Notenderness,clearsymmetricbreathsoundsbilaterally.Heart:PMInotdisplaced;RRR;normalS1/S2;nomurmurs,rub,orgallops.•Abdomen:Soft,nondistended,nontender,⊕BS,nohepatosplenomegaly.•Extremities:Noedema,peripheralpulses2+andsymmetricDifferentialdiagnosisAcutecoronarysyndromeGERDAorticdissectionPericarditisPulmonaryembolismPneumothoraxDiagnosticworkupECGCardiacenzymes(CK-MB,troponin)CXRchestX-rayTransthoracicechocardiogramCardiaccatheterizationCT—chestwithIVcontrast