英文病例表达模板

1、胸痛的英文病例表达Interview the patients with chest pain,Content,History taking Physical examination Patient note writing,Introduction,How can I help you today? What brought you to the hospital/clinic today? What are your concerns?,Chest pain,Onset 开始时间 Precipitating factors 诱因 Duration 持续时间 Relieving factor

2、s 缓解因素 Frequency 发作频率 Associated symptoms 伴随症状 Previous episodes 既往发作 Progression 进展,Interview a patient with chest pain,Hello, Mr. Jones, I am Dr. Zhuang, its 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?

3、 Where do you feel the pain? Can you show me exactly where it is? Does the pain travel anywhere?,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 wors

4、t pain 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

5、around you, light-headed眩晕 Pass out, black out, lose consciousness, syncope晕厥 Heart speeding, palpitation 心慌,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,

6、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, lungs clear to A RRR; normal S1/S2; no murmurs,

7、 rub, or gallops. Abdomen: Soft, nondistended, nontender, BS, no hepatosplenomegaly. Extremities: No edema, peripheral pulses 2+ and symmetric,Differential diagnosis,Acute coronary syndrome GERD Aortic dissection Pericarditis Pulmonary embolism Pneumothorax,Diagnostic workup,ECG Cardiac enzymes(CK-MB, tropon