心内科查房记录模板范文英文回答：Heart Department Ward Round Template.Date: [Date]Patient Name: [Patient Name]MRN: [Medical Record Number]Attending Physician: [Attending Physician]Introduction:Today, I conducted a ward round on [Date] for [Patient Name], who is admitted to the Heart Department under my care. The purpose of this ward round was to assess the patient's current condition, review test results, discuss treatment options, and address any concerns or questionsthe patient may have.Subjective Assessment:During the ward round, I had a detailed conversation with the patient to gather subjective information about their symptoms, medical history, and overall well-being. The patient reported experiencing occasional chest pain, shortness of breath, and fatigue. They also mentioned feeling anxious and worried about their condition. Additionally, the patient shared that they have a family history of heart disease.Objective Assessment:After obtaining subjective information, I proceeded with the objective assessment. I reviewed the patient's vital signs, including blood pressure, heart rate, respiratory rate, and temperature. I also examined the patient's heart sounds, checked for any abnormal murmurs, and assessed their peripheral pulses. Furthermore, I reviewed the results of the patient's recent cardiac tests,including an electrocardiogram (ECG) and echocardiogram.Assessment and Plan:Based on the subjective and objective assessment, I have formulated the following assessment and plan:1. Diagnosis:The patient is diagnosed with coronary artery disease (CAD) based on their symptoms, family history, and abnormal cardiac test results.Further investigations, such as a stress test or coronary angiography, may be required to confirm the diagnosis and assess the severity of the disease.2. Treatment:The patient will be started on a combination of medications, including antiplatelet agents, beta-blockers, and statins, to manage their CAD and reduce the risk ofcardiovascular events.Lifestyle modifications, such as regular exercise, a heart-healthy diet, smoking cessation, and stress management, will be strongly encouraged.3. Follow-up:The patient will be scheduled for regular follow-up appointments to monitor their progress, adjust medications if needed, and address any concerns or questions.Education regarding the signs and symptoms of cardiac emergencies will be provided to the patient and their family members.Conclusion:In conclusion, during today's ward round, I assessed and diagnosed [Patient Name] with coronary artery disease.I have initiated appropriate treatment and lifestyle modifications to manage the condition and reduce the riskof complications. The patient will be closely monitored and provided with necessary education and support. I will continue to follow up with the patient to ensure theirwell-being and address any further needs.中文回答：心内科查房记录模板。
