英文病例表达模板

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,11/7/2009,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,6/20/2018,#,胸痛的英文病例,(bngl),表达,I,nterview the patients with chest pain,第一页，共十七页。,Content,History taking,Physical examination,Patient note writing,第二页，共十七页。,Introduction,How can I help you today?,What brought you to the hospital/clinic today?,What are your concerns?,第三页，共十七页。,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(bn su)病症,Previous episodes 既往发作,Progression 进展,第四页，共十七页。,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?,Where do you feel the pain?,Can you show me exactly where it is?,Does the pain travel anywhere?,第五页，共十七页。,What is the pain like,c,an 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 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?,第六页，共十七页。,Associated symptoms:,Nausea,恶心,Vomiting,呕吐,Cough,phlegm,咳嗽，咳痰,Shortness of breath,呼吸困难,Headache,头疼,(tutng),Dizziness,room spinning around you,light-headed,眩晕,Pass out,black out,lose consciousness,syncope,晕厥,Heart speeding,palpitation,心慌,第七页，共十七页。,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,第八页，共十七页。,Patient note,VS:vital signs WNL:within normal limits,Chest:nontender,lungs clear to A,&,P(auscultation and percussion),Auscultation:decreased breath soundsL/R,Abnormal sounds:wheeze,rub,rale,L/R base/midlung/apex,第九页，共十七页。,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,absent/decreased/NL/bounding,No carotid bruits,第十页，共十七页。,Case,Joseph Short,a 46-year-old male,comes to ED complaining of chest pain,第十一页，共十七页。,HPI:History of present illness,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.,Nothing makes it worse or better.,Nausea,sweating and dyspnea are also present.,Similar episodes have occurred during the past 3 months.,These episodes were precipitated by walking up the stairs,strenuous work and heavy meals.,Pain during these episodes was less severe,lasted 5-10 minutes,and disappeared spontaneously or after taking antacids.,第十二页，共十七页。,Physical examination,Patient is in severe pain,BP 165/85 mmHg(both arms)RR 22/minute,Neck,:no JVD,no bruits.,Chest,:No tenderness,clear symmetric breath sounds bilaterally.,Heart,:PMI not displaced;RRR;normal S1/S2;,no murmurs,rub,or gallops.,Abdomen,:Soft,nondistended,nontender,BS,no hepatosplenomegaly.,Extremities,:No edema,peripheral pulses 2+and symmetric,第十三页，共十七页。,Differential diagnosis,Acute coronary syndrome,GERD,Aortic dissection,Pericarditis,Pulmonary embolism,Pneumothorax,第十四页，共十七页。,Diagnostic workup,ECG,Cardiac enzymes(CK-MB,troponin),CXR chest X-ray,Transthoracic echocardiogram,Cardiac catheterization,CTchest with IV contrast,第十五页，共十七页。,Thank you!,第十六页，共十七页。,内容,(nirng),总结,胸痛,(xin tn),的英文病例表达Interview the patients with chest pain。L/R base/midlung/apex。No clubbing,edema。absent/decreased/NL/bounding。Cardiac enzymes(CK-MB,troponin)。Thank you,第十七页，共十七页。,