内科副主任医师查房记录范文

内科副主任医师查房记录范文英文回答：
Subjective:
The patient is a 65-year-old male with a history of hypertension and hyperlipidemia who presents with a chief complaint of chest pain.
The chest pain is described as a crushing substernal pressure that radiates to the left arm and jaw.
It is associated with shortness of breath, diaphoresis, and nausea.
The pain began at rest and has been unremitting for
the past hour.
Objective:
Vital signs: Blood pressure 140/90 mmHg, heart rate 90 bpm, respiratory rate 20 bpm, temperature 98.6° F (37° C).
Physical examination: Reveals a well-developed, well-nourished male in acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Conjunctivae are pale.
Neck: Supple with no JVD or lymphadenopathy.
Chest: Lungs are clear to auscultation bilaterally. Heart is regular without murmurs, gallops, or rubs.
Abdomen: Soft and non-tender. No hepatomegaly or splenomegaly.
Extremities: No edema or clubbing. Pulses are palpable and equal in all extremities.
Assessment:
Acute coronary syndrome, likely ST-elevation myocardial infarction (STEMI)。

Plan:
Aspirin 325 mg PO.
Nitroglycerin 0.4 mg sublingual every 5 minutes as needed for pain.
Morphine sulfate 2 mg IV every 15 minutes as needed for pain.
Oxygen 2 L/min via nasal cannula.
Electrocardiogram (ECG)。

Cardiac enzymes.
Troponin.
Echocardiogram.
Coronary angiography and possible percutaneous coronary intervention (PCI)。

中文回答：
主诉：
患者为 65 岁男性，有高血压和高脂血症史，主诉胸痛。

胸痛表现为胸骨后压榨性疼痛，放射至左臂和下颌。

伴有呼吸短促、多汗和恶心。

疼痛在休息时开始，过去一小时持续未缓解。

客观：
生命体征，血压 140/90 mmHg，心率 90 bpm，呼吸频率 20 bpm，体温37°C（98.6°F）。

体格检查，显示急性痛苦状态发育良好、营养良好的男性。

头部检查，头部大小正常，无外伤。

瞳孔等大、圆形，对光反
射正常。

结膜苍白。

颈部，柔软，无颈静脉怒张或淋巴结病。

胸部，双肺叩诊清亮。

心脏规律，无杂音、奔马律或摩擦音。

腹部，柔软，无压痛。

无肝脾肿大。

四肢，无水肿或杵状指。

所有四肢的脉搏都可以触及，且对称。

诊断：
急性冠状动脉综合征，可能是 ST 段抬高型心肌梗死 (STEMI)。

计划：
阿司匹林 325 毫克口服。

硝酸甘油 0.4 毫克舌下含服，按需每 5 分钟一次，缓解疼痛。

吗啡硫酸盐 2 毫克静脉注射，按需每 15 分钟一次，缓解疼痛。

经鼻导管吸氧 2 L/分钟。

心电图 (ECG)。

心肌酶。

肌钙蛋白。

超声心动图。

冠状动脉造影和可能的经皮冠状动脉介入治疗 (PCI)。