医学英语病历写作范文
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医学英语病历写作范文
Chief Complaint: Patient presents with chest pain and
shortness of breath for 3 days.
History of Present Illness: The patient, a 55-year-old
male, reports experiencing sudden onset of chest pain 3
days ago. The pain is described as sharp and crushing,
radiating to the left arm. He also reports associated
shortness of breath and diaphoresis. The symptoms are
aggravated with physical activity and alleviated with rest.
There is no history of similar episodes in the past.
Past Medical History: The patient has a history of
hypertension and hyperlipidemia. He is on regular
medications including amlodipine and atorvastatin.
Family History: The patient's father had a history of
myocardial infarction at the age of 60. His mother has
hypertension and diabetes.
Social History: The patient is a non-smoker and denies
alcohol or recreational drug use. He is currently employed
as a manager and reports moderate stress at work. Review of Systems: The patient denies any recent weight
changes, fever, or chills. There is no history of cough,
sputum production, or hemoptysis. He denies any
gastrointestinal symptoms such as nausea, vomiting, or
abdominal pain.
Physical Examination:
- Vital signs: Blood pressure 140/90 mmHg, heart rate 90
bpm, respiratory rate 20 breaths per minute, oxygen
saturation 96% on room air.
- General: The patient appears uncomfortable and
diaphoretic.
- Cardiovascular: Regular rhythm, no murmurs, rubs, or
gallops. Capillary refill time is less than 2 seconds.
- Respiratory: Clear breath sounds bilaterally, no
wheezing or crackles.
Assessment and Plan:
1. Rule out acute coronary syndrome: The patient's
presentation is concerning for acute coronary syndrome
given the symptoms of chest pain, shortness of breath, and diaphoresis. ECG and cardiac enzymes will be obtained to
evaluate for myocardial ischemia.
2. Blood pressure management: The patient's blood
pressure is elevated, and optimization of antihypertensive
medications will be addressed.
3. Lipid management: Given the patient's history of
hyperlipidemia, lipid panel will be obtained to assess for
dyslipidemia and adjust medications as needed.
4. Stress management: The patient's moderate stress at
work will be addressed through counseling and potential
referral to a stress management program.
中文病历：
主诉：患者因胸痛和呼吸急促已3天。
现病史：患者，55岁男性，报告3天前突发胸痛。疼痛描述为尖锐和压迫感，放射至左臂。他还报告伴随呼吸急促和出汗。这些症状在体力活动时加重，在休息时减轻。过去没有类似的发作史。
既往史：患者有高血压和高脂血症病史。他定期服用氨氯地平和阿托伐他汀。
家族史：患者父亲60岁时曾患心肌梗死。他母亲有高血压和糖尿病。 社会史：患者不吸烟，也不饮酒或娱乐药物。他目前是一名经理，报告工作压力适中。
系统回顾：患者否认最近体重改变、发烧或寒战。没有咳嗽、咳痰或咯血的病史。否认任何胃肠道症状，如恶心、呕吐或腹痛。
体格检查：
- 体征：血压140/90 mmHg，心率90 bpm，呼吸频率20次/分钟，室内空气下氧饱和度96%。
- 一般情况：患者看起来不舒服，出汗。
- 心血管：心率规整，无杂音、摩擦音或额外心音。毛细血管再充盈时间小于2秒。
- 呼吸系统：双肺呼吸音清晰，无哮鸣音或啰音。
评估和计划：
1. 排除急性冠脉综合征：患者的表现引起了急性冠脉综合征的怀疑，考虑到胸痛、呼吸急促和出汗的症状。将进行心电图和心肌酶检测以评估心肌缺血。
2. 控制血压：患者的血压升高，将调整抗高血压药物以控制血压。
3. 脂代谢调节：鉴于患者的高脂血症病史，将进行血脂检测以评估脂质代谢紊乱，并根据需要调整药物。 4. 应对压力：将通过咨询和可能的转诊到压力管理项目来应对患者在工作中的适度压力。
