英文病例表达模板

胸痛的英文病例(bìnglì)表达

Interviewthepatientswithchestpain第一页，共十七页。ContentHistorytakingPhysicalexaminationPatientnotewriting第二页，共十七页。IntroductionHowcanIhelpyoutoday?Whatbroughtyoutothehospital/clinictoday?Whatareyourconcerns?第三页，共十七页。ChestpainOnset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(bànsuí)病症Previousepisodes既往发作Progression进展第四页，共十七页。InterviewapatientwithchestpainHello,Mr.Jones,IamDr.Zhuang,it’snicetomeetyou.HowcanIhelpyoutoday?Doyouhavepain?Whendiditstart?Howlonghaveyouhadthispain?Howoftendoesitcomeon?Wheredoyoufeelthepain?Canyoushowmeexactlywhereitis?Doesthepaintravelanywhere?第五页，共十七页。

Whatisthepainlike,canyoudescribeitforme?Isitsharp,dull,burning,pulsating,cramping,orpressure-like?Isitconstant,ordoesitcomeandgo?Onascaleof1to10,with10beingtheworstpainofyourlife,howwouldyourateyourpain?Whatbringsthepainon？Doesanythingmakethepainbetter?Doesanythingmakeitworse?Haveyouhadsimilarpainbefore?第六页，共十七页。Associatedsymptoms:Nausea恶心

Vomiting呕吐Cough,phlegm咳嗽，咳痰Shortnessofbreath呼吸困难Headache头疼(tóuténg)Dizziness,roomspinningaroundyou,light-headed眩晕Passout,blackout,loseconsciousness,syncope晕厥Heartspeeding,palpitation心慌第七页，共十七页。Briefphysicalexam:

whattosaybeforeandduringtheexamIneedtolistentoyourheart/lungsnowCanyouholdyourbreath,please?Canyoutakeadeepbreathforme,please?Canyousit,please?Canyouturntoyourleftside,please?Iamgoingtoexamineyourlegstocheckfluidretention,isthatokaywithyou?Ineedtocheckthepulseinyourarmandlegsnow第八页，共十七页。PatientnoteVS:vitalsignsWNL:withinnormallimitsChest:nontender,lungscleartoA&P(auscultationandpercussion),Auscultation:decreasedbreathsounds[L/R]Abnormalsounds:wheeze,rub,rale[L/R][base/midlung/apex]第九页，共十七页。

CV:cardiovascularS1,S2WNLRegularrate&rhythm,RRRNorub/gallops/murmursittingandsupine(noRGM)NoJVD(jugularvenousdistention)PMInotdisplaced(pointofmaximalimpulse)Noclubbing,edemaCarotid,radial,DP(dorsipedis),pulseNL&equalB/Labsent/decreased/NL/boundingNocarotidbruits第十页，共十七页。Case

JosephShort,a46-year-oldmale,comestoEDcomplainingofchestpain第十一页，共十七页。HPI:Historyofpresentillness46yoMc/ochestpain.Thepainstarted40minutesbeforehepresentedtoEDwithasteady7/10pressuresensationinthemiddleofhischestthatradiatedtotheleftarmandtheneck.Nothingmakesitworseorbetter.Nausea,sweatinganddyspneaarealsopresent.Similarepisodeshaveoccurredduringthepast3months.Theseepisodeswereprecipitatedbywalkingupthestairs,strenuousworkandheavymeals.Painduringtheseepisodeswaslesssevere,lasted5-10minutes,anddisappearedspontaneouslyoraftertakingantacids.第十二页，共十七页。PhysicalexaminationPatientisinseverepainBP165/85mmHg(botharms)RR22/minuteNeck:noJVD,nobruits.Chest:Notenderness,clearsymmetricbreathsoundsbilaterally.Heart:PMInotdisplaced;RRR;normalS1/S2;nomurmurs,rub,orgallops.Abdomen:Soft,nondistended,nontender,⊕BS,nohepatosplenomegaly.Extremities:Noedema,peripheralpulses2+andsymmetric

第十三页，共十七页。DifferentialdiagnosisAcutecoronarysyndromeGERDAorticdissectionPericarditisPulmonaryembolismPneumothorax第十四页，共十七页。DiagnosticworkupECGCardiacenzymes(CK-MB,troponin)CXRchestX-rayTransthoracicechocardiogramCardiaccatheterizationCT—chestwithIVcontrast第十五页，共十七页。Thankyou!第十六页，共十七页。内容