英文病例表达模板.pptx

胸痛的英文病例表达胸痛的英文病例表达Interview the patients with chest painContentHistory takingPhysical examinationPatient note writingIntroductionHow can I help you today?What brought you to the hospital/clinic today?What are your concerns?Chest painOnset 开始时间开始时间Precipitating factors 诱因诱因Duration 持续时间持续时间Relieving factors 缓解因素缓解因素Frequency 发作频率发作频率Associated symptoms 伴随症状伴随症状Previous episodes 既往发作既往发作Progression 进展进展Interview a patient with chest painHello,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?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 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 恶心恶心 Vomiting 呕吐呕吐Cough,phlegm 咳嗽，咳痰咳嗽，咳痰Shortness of breath 呼吸困难呼吸困难Headache 头疼头疼Dizziness,room spinning around you,light-headed眩晕眩晕Pass out,black out,lose consciousness,syncope晕厥晕厥Heart speeding,palpitation 心慌心慌Brief physical exam:what to say before and during the examI need to listen to your heart/lungs nowCan 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 nowPatient noteVS:vital signs WNL:within normal limitsChest:nontender,lungs clear to A&P(auscultation and percussion),Auscultation:decreased breath soundsL/R Abnormal sounds:wheeze,rub,rale L/R base/midlung/apexCV:cardiovascular S1,S2 WNLRegular rate&rhythm,RRRNo rub/gallops/murmur sitting and supine(no RGM)No JVD(jugular venous distention)PMI not displaced(point of maximal impulse)No clubbing,edemaCarotid,radial,DP(dorsi pedis),pulse NL&equal B/L absent/decreased/NL/boundingNo carotid bruitsCase Joseph Short,a 46-year-old male,comes to ED complaining of chest painHPI:History of present illness46 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.Physical examinationPatient is in severe painBP 165/85 mmHg(both arms)RR 22/minuteNeck: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 Differential diagnosisAcute coronary syndromeGERDAortic dissectionPericarditisPulmonary embolismPneumothoraxDiagnostic workupECGCardiac enzymes(CK-MB,troponin)CXR chest X-rayTransthoracic echocardiogramCardiac catheterizationCTchest with IV contrastThank you!