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1、胸痛的英文病例表达InterviewthepatientswithchestpainContentHistorytakingPhysicalexaminationPatientnotewritingIntroductionHowcanIhelpyoutoday?Whatbroughtyoutothehospital/clinictoday?Whatareyourconcerns?ChestpainOnset开始时间Precipitatingfactors诱因Duration持续时间Relievingfactors缓解
2、因素Frequency发作频率Associatedsymptoms伴随症状Previousepisodes既往发作Progression进展InterviewapatientwithchestpainHello,Mr.Jones,IamDr.Zhuang,it’snicetomeetyou.HowcanIhelpyoutoday?Doyouhavepain?Whendiditstart?Howlonghaveyouhadthispain?Howoftendoesitcomeon?Wheredoyoufeelthepa
3、in?Canyoushowmeexactlywhereitis?Doesthepaintravelanywhere?Whatisthepainlike,canyoudescribeitforme?Isitsharp,dull,burning,pulsating,cramping,orpressure-like?Isitconstant,ordoesitcomeandgo?Onascaleof1to10,with10beingtheworstpainofyourlife,howwouldyourateyourpain?
4、Whatbringsthepainon?Doesanythingmakethepainbetter?Doesanythingmakeitworse?Haveyouhadsimilarpainbefore?Associatedsymptoms:Nausea恶心Vomiting呕吐Cough,phlegm咳嗽,咳痰Shortnessofbreath呼吸困难Headache头疼Dizziness,roomspinningaroundyou,light-headed眩晕Passout,blackout,loseconscio
5、usness,syncope晕厥Heartspeeding,palpitation心慌Briefphysicalexam:whattosaybeforeandduringtheexamIneedtolistentoyourheart/lungsnowCanyouholdyourbreath,please?Canyoutakeadeepbreathforme,please?Canyousit,please?Canyouturntoyourleftside,please?Iamgoingtoexamineyourlegs
6、tocheckfluidretention,isthatokaywithyou?IneedtocheckthepulseinyourarmandlegsnowPatientnoteVS:vitalsignsWNL:withinnormallimitsChest:nontender,lungscleartoA&P(auscultationandpercussion),Auscultation:decreasedbreathsounds[L/R]Abnormalsounds:wheeze,rub,rale[L/R][ba
7、se/midlung/apex]CV:cardiovascularS1,S2WNLRegularrate&rhythm,RRRNorub/gallops/murmursittingandsupine(noRGM)NoJVD(jugularvenousdistention)PMInotdisplaced(pointofmaximalimpulse)Noclubbing,edemaCarotid,radial,DP(dorsipedis),pulseNL&equalB/Labsent/decreased/NL/bound
8、ingNocarotidbruitsCaseJosephShort,a46-year-oldmale,comestoEDcomplainingofchestpainHPI:Historyofpresentillness46yoMc/ochestpain.Thepainstarted40minutesbeforehepresentedtoEDwi