英文病例表达模板

Brief physical exam:
what to say before and during the exam
I need to listen to your heart/lungs now Can you hold your breath, please? Can you take a deep breath for me, please? Can you sit, please? Can you turn to your left side, please? I am going to examine your legs to check fluid
retention, is that okay with you? I need to check the pulse in your arm and legs now
Patient note
VS: vital signs WNL: within normal limits Chest: nontender,
• What is the pain like, can you describe it for me? • Is it sharp, dull, burning, pulsating, cramping, or
pressure-like? • Is it constant, or does it come and go? • On a scale of 1 to 10, with 10 being the worst pain
46 yo M c/o chest pain.
The pain started 40 minutes before he presented to ED with a steady 7/10 pressure sensation in the middle of his chest that radiated to the left arm and the neck.
Content
• History taking • Physical examination • Patient note writing
Introduction
How can I help you today? What brought you to thewenku.baidu.comhospital/clinic
today? What are your concerns?
Chest pain
Onset 开始时间 Precipitating factors 诱因 Duration 持续时间 Relieving factors 缓解因素 Frequency 发作频率 Associated symptoms 伴随症状 Previous episodes 既往发作 Progression 进展
of your life, how would you rate your pain? • What brings the pain on？ • Does anything make the pain better? • Does anything make it worse? • Have you had similar pain before?
Associated symptoms:
Nausea 恶心 Vomiting 呕吐 Cough, phlegm 咳嗽，咳痰 Shortness of breath 呼吸困难 Headache 头疼 Dizziness, room spinning around you, light-headed眩晕 Pass out, black out, lose consciousness, syncope晕厥 Heart speeding, palpitation 心慌
absent/decreased/NL/bounding No carotid bruits
Case
Joseph Short, a 46-year-old male, comes to ED complaining of chest pain
HPI: History of present illness
CV: cardiovascular
S1, S2 WNL Regular rate & rhythm, RRR No rub/gallops/murmur sitting and supine (no RGM) No JVD ( jugular venous distention) PMI not displaced (point of maximal impulse ) No clubbing, edema Carotid, radial, DP(dorsi pedis), pulse NL & equal B/L
Interview a patient with chest pain
Hello, Mr. Jones, I am Dr. Zhuang, it’s nice to meet you. How can I help you today?
Do you have pain? When did it start? How long have you had this pain? How often does it come on? Where do you feel the pain? Can you show me exactly where it is? Does the pain travel anywhere?
lungs clear to A&P (auscultation and percussion),
Auscultation: decreased breath sounds[L/R] Abnormal sounds: wheeze, rub, rale
[L/R] [base/midlung/apex]