心絞痛英文病歷

1、Sample History and Physical NoteCharting Plus ? - Electronic MedicalRecordsNote for Jane Doe on 4/4/03 - Chart 5407Chief Complaint (1/1):This 62 year old female presents today for evaluation of angina.Associated signs and symptoms:Associated signs and symptoms include chest pain,nausea, pain radiati

2、ng to the arm and pain radiating to the jaw.Context: The patient has had no previous treatments for this condition. Duration: Condition hasexisted for 5 hours.Quality: Quality of the pain is described by the patient as crushing. Severity: Severity of condition issevere and unchanged.Timing (onset/fr

3、equency):Onset was sudden and with exercise.Patient has the following coronary risk factors:smoking 1 packs/day for 40 years and elevatedcholesterol for 5 years. Patients elevated cholesterol is not being treated with medication. Menopauseoccurred at age 53.Allergies: No known medical allergies.Medi

4、cation History: Patient is currently taking Estraderm 0.05 mg/day transdermal patch. PMH: Past medicalhistory unremarkable.PSH: No previous surgeries.Social History: Patient admits tobacco use She relates a smoking history of 40 pack years. Family History:Patient admits a family history of heart att

5、ack associated with father (deceased). ROS: Unremarkable withexception of chief complaint.General: Patient is a 62 year old female who appears pleasant, her given age, well developed, oriented, wellnourished, alert and moderately overweight.Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6

6、Height: 5 ft. 2 in. Weight: 150 lbs. HEENT:Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neckmasses.Ocular motility exam reveals muscles are intact.Pupil exam reveals round and equally reactive to light and accommodation.There is no conjunctival infla

7、mmation nor icterus.Inspection of nose reveals no abnormalities.Inspection of oral mucosa and tongue reveals no pallor or cyanosis.Inspection of the tongue reveals normal color, good motility and midline position. Examination oforopharynx reveals the uvula rises in the midline.Inspection of lips, te

8、eth, gums, and palate reveals healthy teeth, healthy gums, no gingival hypertrophy,no pyorrhea and no abnormalities.Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitancepalpable.Thyroid examination reveals smooth and symmetric gland with no enlargement, te

9、nderness or massesnoted.Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid andvertebral arteries.Jugular veins examination reveals no distention or abnormal waves were noted.Neck lymph nodes are not noted.Back: Examination of the back reveals no vertebr

10、al or costovertebralangle tenderness andno kyphosis or scoliosis noted.Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours arenormal and normal expansion.Chest palpation reveals no abnormal tactile fremitus.Lungs: Chest percussion reveals resonance.A

11、ssessment of respiratory effort reveals even respirations without use of accessory muscles anddiaphragmatic movement normal.Auscultation of lungs reveal diminished breath sounds bibasilar.Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in themidclavicul

12、ar line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heartauscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormalsplitting of the second heart sound which moves normally with respiration.Right leg and left l

13、eg shows evidence of edema +6.Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.Palpation of liver reveals no abnormalities with respect to size, tenderness or masses.Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination

14、 ofabdominal aorta shows normal size without presence of systolic bruit.Extremities: Extremities:Right thumb and left thumb reveals clubbing.Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equaland normal.The brachial, radial and ulnar pulses

15、in the upper extremities are equal and normal. Examination ofperipheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pittingand pulses are full to palpation.Femoral pulses are 2 /4, bilateral.Pedal pulses are 2 /4, bilateral.Neurological: Testing of cranial

16、 nerves reveals nerves intact.Oriented to person, place and time.Mood and affect normal and appropriate to situation.Deep tendon reflexes normal.Touch, pin, vibratory and proprioception sensations are normal.Babinski reflex is absent.Coordination is normal.Speech is not aphasic.Musculoskeletal: Musc

17、le strength is 5/5 for all groups tested.Gait and station examination reveals midposition without abnormalities.Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.Skin is warm and dry withnormal turgor and there is no icterus.Lymphatics: No lymphadenopathy noted.Impression: Angina

18、pectoris, other and unspecified.Plan: Diagnostic & Lab Orders:Ordered serum creatine kinase isoenzymes (CK isoenzymes).Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report.The following cardiac risk factor modifications are recommended:quit smoking and reduceLDL

19、cholesterol to below 120 mg/dl.Patient Instructions:Patient received literature on angina.Prescriptions:nitroglycerin Dosage: 0.1 mg/hr film, extended releaseSig: as needed for chest painDispense:20 Refills: 0 Allow Generic: Nodigoxin Dosage: 0.125 mg tablet Sig: 1 qd Dispense: 30 Refills: 0 Allow G

20、eneric: Yes_ A. Cardiologist, MDCharting Plus ? - ElectronicSample Billing StatementMedical RecordsBilling Statement - Friday, April 04, 2003Provider:Patient:A. Cardiologist, MDJane Doe, Chart 5407 1231 8thStreet, Suite 222 West Des Moines, IA 50265Diagnoses1. 413.9 Other And Unspecified Angina Pect

21、orisTreatments1. 93000 Electrocardiogram, Routine ECG With At Least 12 Leads; WithInterpretation And Report Related Diagnoses: Modifiers: Units:2. 82552 Creatine Kinase (CK), (CPK); IsoenzymesRelated Diagnoses:Modifiers:Units:3. 99212 Office Or Other Outpatient Visit For The Evaluation And Managemen

22、t OfAn Established Patient, Which Requires At Least Two Of These Three KeyComponents: A Problem Focused History; A Problem Focused Examination;Straightforward Medical Decision Making. Counseling And/Or Coordination Of CareWith Other Providers Or Agencies Are Provided Consistent With The Nature Of Th

23、eProblem(s) And The Patients And/Or Familys Needs. Usually, The PresentingProblem(s) Are Self Limited Or Minor. Physicians Typically Spend 10 MinutesFace-To-Face With The Patient And/Or Family.Related Diagnoses:Modifiers:Units:Referring Physician: Marcus Welby, MDDate Last Seen: 04/19/2002Charting P

24、lusSample PrescriptionElectronic Medical RecordsA. Cardiologist, MDDEA#:Name: Jane DoeAddr: 1231 8thStreet, Suite 222West Des Moines, IA 50265digoxin0.125 mg tablet1 qdX_ X_Substitution Permitted Dispense as written Refills: 0Disp: 30Allow Generic: YesA. Cardiologist, MDDEA#:Name: Jane DoeAddr: 1231

25、 8thStreet, Suite 222West Des Moines, IA 50265nitroglycerin0.1 mg/hr film, extended release as needed for chest painX_ X_Substitution Permitted Dispense as written Refills: 0Disp: 20Allow Generic: NoDate: 4/4/03Date: 4/4/03Charting Plus ? - ElectronicA. Cardiologist, MDSample Patient InstructionMedi

26、cal RecordsPatient Instructions for Jane Doe on 4/4/03ANGINAWhat is it?Angina is chest pain due to a lack of oxygen to the heart most often occurring in men age 35 or older andpostmenopausal women.It is usually located right under the breast bone.Physicaland emotional stress, as well as eating heavy

27、 meals, can bring it on.In a healthy person, thesestresses are easily handled.In a person with an underlying heart condition like coronary arterydisease, heart valve problem, arrhythmias or high blood pressure, the heart doesnt get enough blood (i.e. notenough oxygen to the heart muscles).Other caus

28、es could be due to a hyperactivethyroid disorder or anemia.People more likely to have angina may also have diabetes mellitus,be overweight, smoke, have a poor diet with lots of salt and fat, fail toexercise, have a stressfulworkload or have a family history of coronary artery disease.Signs and sympt

29、oms:* Pain in chest described as tightness, heavy pressure, aching or squeezing.* The pain sometimes radiates to the jaw, left arm, teeth and/or outer ear.* Possibly a left-sided numbness, tingling, or pain in the arm, shoulder, elbow or chest.* Occasionally a sudden difficulty in breathing occurs.*

30、 Pain may be located between the shoulder blades.Treatment:* Nitroglycerin relieves the immediate symptoms of angina in seconds.Carry it with you at alltimes.* Other medications may be prescribed for the underlying heart problems.It is important to takethem as prescribed by your doctor.* Surgery may

31、 be necessary to open the blocked coronary arteries (balloon angioplasty) or to bypass them.* Correct the contributing factors you have control over.Lose weight, dont smoke, eat a low-salt, low-fat diet and avoid physical and emotional stresses that cause angina. Such stressors include anger,overwor

32、king, going between extremes in hot and cold, sudden physical exertion and high altitudes(pressurized airplanes arent a risk).Practice relaxation techniques.* Exercise! Discuss first what you are able to do with your doctor and then go do it.* Even with treatment, angina may result in a heart attack

33、, congestive heart failure or a fatal abnormalheartbeat. Treatment decreases the odds that these will occur.* Let your doctor know if your angina doesnt go away after 10 minutes, even when you have taken anitroglycerin tablet. Call if you have repeated chest pains that awaken you from sleep regardless if thenitroglycerin helps.If your pain changes or feels different, call your doctor or call911 if the pain is severe.Sample Referral Let