First Visit 初诊医务英语会话

First Visit 初诊医务英语会话 WOMAN, AGED 29 女性，29岁 Doctor I see from your notes you were in hospital ten years ago with thyroid trouble. 医生 我从你的病历中得知，你10年前曾因甲状腺功能混乱住过院。 Patient Yes, that’s right. And now I’ve got stomach trouble and my doctor sent me here. 病人 对，是这样的。现在我有犯了胃病，我的医生介绍我到您这里来看病。 Doctor What has actually been happening since the thyroid trouble? 医生 自从得了甲状腺疾病以来，有过那些症状, Patient All sorts of things. I’ve been feeling very depressed for a year. 病人 症状可多呢。一年来，我精神非常不好。 Doctor Did you go to your doctor? 医生 看过医生吧, Patient Yes, when it got bad. He gave me some Valium tablets to slow me down but they slowed me to a halt. I didn’t do anything but sleep. 病人 难受时看过。他让我服用安定药片，使我镇静。我整天昏昏欲睡，除了睡觉外，我什么事也干不了。 Doctor Did they affect you in any other way? 医生 还有其他症状吗, Patient Yes. I got indigestion. 病人 有，我最近消化不良。 Doctor Did he give you anything for that? 医生 医生给你吃过什么药吗, Patient Yes. He gave me some medicine and then it was all right. 病人 给了，他给我开点药，我吃了就好了。 Doctor How does the indigestion affect you? 医生 消化系统怎么不好受, Patient All the food stays up here (indicating chest.) 病人 医学英语:www.hope.net.cn/english/index.html吃进的东西都停在这里(指胸部)。 Doctor When do you get it? 医生 什么时候觉得难受 Patient Two to three hours after food. 病人 饭后两三个小时。 Doctor What is it like? A pain? 医生 怎么不好,疼痛吗, Patient Yes, a pain. 病人 是的，很痛。 Doctor What kind? Burning, stabbing? 医生 怎么个痛法,烧痛还是刺痛, Patient It feels like some wind there and I want to get rid of it. 病人 肠胃里胀气，我想把气排掉。 Doctor Do you belch? 医生 打嗝吗, Patient Not much. 病人 不常打嗝。 Doctor Does it bother you at night? 医生 夜间犯病吗, Patient No. 病人 不。 Doctor It comes on when you are hungry? 医生 饥饿时发作吗, Patient Yes, I have a terrible pain in my stomach and I feel I’ll collapse if I don’t eat straight away. 病人 对，饥饿时胃部特别疼痛，如果不马上吃些东西，我就支持不住。 Doctor How is your appetite? 医生 胃口怎么样, Patient Very poor. 病人 很差。 Doctor Did you always have a bad one? 医生 胃口一向不好吗, Patient No, it started to deteriorate ten years ago. 病人 不，10年前才开始疼的。 Doctor Has it changed much in the last few months? 医生 近几个月变化大吗, Patient I think the medicine must push the food down and then I fell hungry? 病人 服药后，食物能够往下走了，我也感觉到饿了, Doctor What about your weight? 医生 你体重怎么样, Patient I’m losing weight. 病人 体重在下降。 Doctor How much do you weight now? 医生 现在体重是多少, Patient 8st1lb. 病人 113磅 (1st = 14lb lb=磅) Doctor And how much did you weigh a year ago? 医生 一年前体重是多少, Patient 9st 病人 126磅 Doctor What about your bowels? 医生 大便情况如何, Patient Terrible. 病人 很不好。 Doctor In what way? 医生 怎么不好? Patient I’m constipated. 病人 常常便秘。 Doctor How often do you have them opened? 医生 几天大便一次, Patient Only when I take medicine. 病人 只有吃了药才能大便。 Doctor Every day? 医生 每天都解大便吗, Patient No, every other day. 病人 不，隔一天一次。 Doctor Does warm weather affect you? 医生 天气暖和时，你难受吗, Patient No. I prefer warm weather. I sweat less. 病人 不，我喜欢温暖气候， 我出汗不多。 Doctor Do you always sweat? 医生 你经常出汗吗, Patient Yes, but more recently. 病人 是的，最近出汗更多了。 Doctor All over your body? 医生 是全身出汗吗, Patient Yes, all over. 病人 是的 Doctor Do you feel depressed, nervous, edgy, and irritable? 医生 你觉得抑郁、不安、急躁和爱激动吗, Patient I was worse before I got my job. 病人 是的，找到工作以前，我的病情更重。 Doctor When did you start that? 医生 这样多久了, Patient A month ago. 病人 1个月前。 Doctor Have you been fidgety, have your hands been shaky? 医生 你一直坐立不安、双手颤抖吗, Patient When I was coming here. 病人 我到这里时就是这样。 Doctor At times of stress? 医生 是在精神紧张的时候发作吗, Patient Yes. And when something riles me. 病人 对，或者惹我生气时。 Doctor Any trouble with your eyes? 医生 眼睛有什么毛病吗, Patient No 病人 没有。 Doctor Periods regular? 医生 月经规律吗, Patient Every month since I had my baby. 病人 有了孩子后，每月都有。 Doctor When was that? 医生 那是什么时候, Patient Five years ago. 病人 5年以前。 Doctor Do you feel restless? 医生 你感到躁动不安吗, Patient I couldn’t concentrate till I got my job but now I have to, 病人 未找到工作以前，我精力一直集中不起来，如今不得不专心工作 Doctor Is there anything else you’ve noticed? 医生 你还有别的感觉吗, Patient No 病人 没有 Doctor Has anyone in your family had thyroid trouble? 医生 家中还有别人有过甲状腺疾病吗, Patient No. I have one sister and two brothers. 病人 没有。我有一个姐姐和两个兄弟。 Doctor Are they well? 医生 他们都好吗, Patient Yes. 病人 是的。 医务人员常用医务英语会话 Now let me examine your nose. 现在让我检查你的鼻子。 Let me take a look in your ears, first. 首先让我看一下你的耳朵 You need a thorough examination. . 你需要做一个全面检查。 It is not serious. 病情不严重。 Well, your main trouble is shortness of breath? 你的主要病症是气短，对吗, Seeing a Doctor看病医务英语会话 Seeing a Doctor 看病 Doctor The baby has a heart murmur, but this may be normal. Does he seem to be pretty active? 医生 这个婴儿心脏有杂音，但杂音可能是正常的。他看起来很活泼, Mother Oh yes. 母亲 哦，很活泼。 Doctor Does he ever turn blue after eating or after crying? 医生 他吃奶或哭闹后有发青紫的现象吗, Mother Well. I haven’t noticed anything like that. 母亲 噢，我没有注意到那样的情况。 Doctor Does he seem to get tired very often? 医生 他经常显得疲劳吗, Mother When he cries a lot he does. 母亲 当他哭多了就显得疲劳。 Doctor We’ll watch this condition. Is he on any other food than the formula? 医生 我们要注意这种情况。他除了吃配方奶以外还吃其他食物吗, Mother No 母亲 不吃。 Doctor How much formula is he taking? 医生 他吃多少配方奶, Mother Five ounces. 母亲 5盎司。 Doctor I mean the total, in a day. Is he up to a quart? 医生 我的意思是一天的总量是多少,能吃到1夸脱吗, Mother Just about that. 母亲 差不多1夸脱。 Doctor Well, we usually don’t like them to get more than a quart a day. We’ll start him on some solids. He’s gaining weight nicely. I see„No other problems? 医生 厄，我们一般不愿意让他们一天吃1夸脱以上。要开始给他吃固体食物。他的体重会增加的很好，„„没 有其他问 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 了吧, Mother I don’t think so. 母亲 没有了。 1、What can do for you? 你有什么事, 2、May I help you? 我能帮你什么忙, 3、Please take a seat! please sit down! 请坐。 4、Wait a moment, please. 请等一等。 5、Sorry to have kept you waiting. 对不起让你久等了。 6、It is not serious. 病情不严重。 7、Don’t worry. There is nothing to worry about. 不必顾虑。 8、You need a thorough examination. 你需要做一个全面检查。 9、You will have to stay in hospital for sevral days. 你需要在医院里住几夭。 We think that you had better be hospitalized. 我们认为你最好住进医院来。 10、You should stay in bed for a few days. 你需要卧床几天。 11、You can keep on working. You can carry on with your work. 可以继续工作。 12、You should be very careful for a week or two. 这一两周内，你需要很注意。 13、Try to relax and keep calm. 尽量放松保持镇静。 14、You’ll soon be all right. 你很快就会好起来的。 15、1’m sure this medicine will help you a great deal. 这药对你肯定会很有效的。 16、Feeling well again is a rather slow process, I’m afraid. 恐怕痊愈将是一个很慢的过程。 17、You will have to wait for twenty minutes. 你需要等20分钟。 18、Complete recovery will take a rather long time. 彻底恢复需要一段很长的时间。 19、You will have to come here for periodical check-ups. 你需要定期来门诊检查。 20、If you feel worse, please come back to the clinic right away. 要是你觉着病加重了，就请马上来门诊。 21、If you feel worried, don’t hesitate to go to the clinic anytime, day or night. 你要觉着难受，无论白天黑夜都赶紧上医院看去。 22、I’ll come right away. 我马上就来。 23、I’m going to make arrangements for your admission. 我去给你安排住院。 24、Please come with your interpreter next time. 下次请带翻译来。 25、Do you understand what I’m saying? 你明白我的话吗, 26、Is there anything else you would like me to explain to you? 你看在哪些方面还需要解释呢, 27、Shall I explain it again? 需等我海解释一遍吗, 28、If the trouble persists come back again. 要是情况还不见好，就请你再来门诊吧。 29、There doesn’t seem to be anything serious, but we’11 take an x-ray just to be certain. 不象有什么严重情况，但还是要拍张x线片肯定一下。 30、Please wait until we get the result of the x-ray (blood test). 请等一下，我们需要看一下X线片(验血)的结果。 31、It’s difficult to say just now exactly what’s wrong. 现在还不好说是什么问题。 32、This is quite common among people of your age. 在您这样岁数人当中，这可太寻常了。 This often happens to people of your age. 这种情况经常发生在你这样岁数的人。 This often occurs at your age. 这就经常出在你这种岁数上。 33、This kind of illness usually occurs among people whose work requires a lot of concentration(who undergo a lot of stress). 这种病通常发生在工作要求精神高度集中的(精神紧张的)人们当中。 34、I suggest you do some light exercises. 我建议你做些轻微的锻炼。 I suggest you have a course of acupuncture. 我自颇胞一个疗程的针灸。 I suggest that you get physiotherapy treatment. 我建议你作理疗。 I suggest that you take Chinese herbs. 我建议你吃中药。 35、I would like to transfer you to the gynecology (surgery, dermatology, urology department). 我要将你转到妇科(外科、皮科、泌尿科)去。 36、Your WBC(RBC, hemoglobin, urine stool, sputum) should be checked. 你的白细胞(红细胞，血红蛋白，尿，大便，痰)需要检查一下。 37、A smear should be taken. 需要做个涂片。 A culture should be done. 需要做个培养。 38、Please don’t eat anything tomorrow morning before blood test. 明早查血以前不要吃东西。 39、Please wait for the result of your hemoglobin test. 请等一下你的血红蛋白化验结果。 40、What’s your trouble? 你哪里觉着不好, 41、How long have you been feeling unwell? 你不舒服多久了。 42、What medicine did you take? 你吃的是什么药, 43、Have you taken any medicine? 你吃过什么药吗, 44、Did you take your temperature? 你试过体温吗, 45、Do you smoke (drink)? 你吸烟(喝酒)吗, 46、Have you any temperature (a cough, a bed headach)? 你发烧(咳嗽，剧烈的头痛)吗, 47、Have your ever had jaundice (low grade fever, any chronic ailments, cold sweats at night, attacks of asthma)? 你有过黄疸(发低烧，任何慢性病，夜间出冷汗，哮喘发作)吗, 48、Do you sufer from heartburn stomachaches(loose bowel movements, chest pains)? 你的胃有过烧心感(稀便，胸痛)吗, 49、Do your want to have your tooth extracted, tooth filled, dressing changed, blood pressure checked? 你要拔牙(补牙，换药，量血压)吗, 50、Let me examine you please. 我给你检查一下。 51、Please take off your shoes and lie down. 请脱鞋，躺下。 52、Please unbutton your shirt and loosen your belt. 请解开上衣的扣子，松开腰带。 53、Please take off your trousers. 请脱下裤子。 54、Please lie on your back (stomach, right side, left side). 请仰卧(俯卧，右侧卧，左侧卧)。 55、Please bend your knees. 请屈膝。 56、,pleare relax. 请放松。 57、Please breathe deeply(normally). 请深呼正常呼吸)。 58、Please stick Out your tongue. 请伸出舌头。 59、Please let me feel your pulse. 让我摸摸你的脉搏。 60、Let me take your blood pressure. 我给你量一下血压。 61、Pleas, lift your left leg(right leg). 请抬起你的左腿(右腿)。 62、Please open your mouth and say "Ah". 请张开口说“啊”。 63、It is normal(essentially normal). 结果正常(基本正常)。 64、Have you ever received any treatment before? 你以前治过吗, 65、Has it gotten worse? 情况变坏了吗, 66、Has it happened before? 这种情况以前发生过吗, 67、Are you feeling better? 你觉着好一些吗, 68、Is the pain gentting less? 疼痛减轻些了吗, 69、Does it still hurt? 还疼吗, 70、How long have you had this pain? 你从什么时侯开始有这种痛的? 71、What kind of pain is it? 是什么样的痛, 72、Please tell me something of your past illnesses. 告诉我你过去的病史。 73、Is there any blood in your stool(urine, sputum)? 你的大便里(尿里，痰里)有血吗, forensic medicine 法医学 doctor, physician 医生，医师，内科医师 family doctor 家庭医生 pediatrician, pediatrist 儿科医师 gynecologist 妇科医师 tocologist, obstetrician 产科医师 neurologist 神经专家 psychiatrist 精神病学专家 ophthalmologist, oculist 眼科专家 dentist, odontologist 牙医师 surgeon 外科医师 anesthetist, anaesthetist 麻醉师 nurse 护士 hospital 医院 clinic 诊所 sanatorium 疗养院 health 健康 healthy (个人)健康 wholesome 合乎卫生的，有益于健康的 hygiene 卫生 to get vaccinated 接种 sick person, patient 病员，患者 to be sick, to be ill 患病 sickly 多病 ailment, complaint 疾病 pain 疼，痛 indisposition, slight illness 不适 unwell, indisposed 不适的 affection, disease 疾病 ulcer 溃疡 wound 创伤，伤口 lesion 损害 injury 损伤 rash, eruption 疹 spot 点，斑 pimple 丘疹，小疮 blackhead 黑头粉刺 blister 水疱 scab, boil 痂 scar 癜痕 wart 疣,肉赘 callus, callosity 胼胝 corn 鸡眼 chilblain 冻疮 bruise 挫伤 ecchymosis 瘀癍 bump 肿 swelling 肿胀 contusion 挫伤 sprain, twist 扭伤 fracture 骨折 symptom 症状 diagnosis 诊断 case 病例 incubation 潜伏 epidemic 流行病 contagion 传染 fever 热 attack, access, fit 发作 coughing fit 咳嗽发作 to take to one’s bed 卧床 to sneeze 打喷嚏 faint, fainting fit 晕厥 vertigo, dizziness 眩晕 to feel sick 恶心 to lose consciousness 失去知觉 concussion 震荡 coma 昏迷 diet 饮食 treatment 疗法 to get better, to improve 好转 cure 治愈 relapse 复发 询问病情的常用句子 Are you feeling all right? 您是感觉好吗? Are you feeling nausea? 您是感觉恶心吗? Are your bowels acting properly? 您的肠能适当地行动吗? Are your bowels regular? 您的肠的运动是规则吗? Did you have pains here before? 您这里有以前痛吗? Do you cough? 你咳嗽吗, Do you feel short of breath sometimes? 您有时感觉呼吸急促吗? Do you feel short-winded? 你有时感觉短促的喘气吗, Do you feel tired? 您感到疲乏吗? Do you have any appetite? Do you have difficulty breathing? 您有胃口吗? 您有呼吸困难吗? Does it hurt? 心脏感到痛吗, Have you ever had this experience before? 您以前曾经有这经验吗? Have you got any chronic diseases in the past? 您从前得过慢性疾病吗? Have you got any feeling of nausea? 您有恶心的感觉吗? Have you lost weight recently? 您的体重最近减轻了吗, Have you taken anything for it? 您为它采取了各种方式了吗, How about your appetite? 您的胃口怎么样? How bad is it? 它有多么坏, How far pregnant are you? 您怀孕多久了, How long has it been this way? 这样多久了, How long has this been going on? 继续这样多久了, How long have you been ill? 您这样不舒服有多久了, How long have you been like this? 您像这样有多久了, How long have you had it? 你有这个毛病有多久了, How long have you had this trouble? 你有这麻烦多久了, How're you feeling now? 您现在感觉怎么样了, How's your rheumatism? 您的关节感觉怎么样, How's your sleep? 你的睡眠情况怎么样, Since when have you been feeling like this? 您感觉象这样是从什么时候开始的, What did you eat yesterday? 您昨天吃了什么? What do you complain of? 您说什么? What hurts you? 你那里痛, What seems to be the matter? 似乎是什么问题? What seems to be the trouble? 似乎是什么麻烦?友情忠告:经常性的参加医学检验:www.hope.net.cn/inspection/index.html 将疾病尽 早控制。 What sort of pain do you get there? 您什么地方痛, What's the matter with you? 怎么了您? Details个人资料 Name: Joe Bloggs (姓名:乔。伯劳格斯) Date: 1st January 2000(日期:2000年1月1日) Time: 0720(时间:7时20分) Place: A&E(地点:事故与急诊登记处) Age: 47 years(年龄:47岁) Sex: male(性别:男) Occupation: HGV(heavy goods vehicle ) driver(职业:大型货运卡车司机) PC(presenting complaint)(主诉) 4-hour crushing retrosternal chest pain(胸骨后压榨性疼痛,小时) HPC(history of presenting complaint)(现病史) Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.(起病特征:胸骨后压榨性疼痛,小时，向颈与双臂放www.hope.net.cn， 5-10分钟内渐起病) Duration: persistent since onset(间期:发病起持续至今) Severe: “worst pain ever had”(严重性:“从未痛得如此厉害过) Relieving/exacerbating factors缓解与恶化因素 GTN(glyceryl trinitrate) provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.(硝酸甘油平时能在数分钟内缓解疼痛，但本次无效，无其它缓解和恶化因素。) Associated symptoms 相关症状 Nausea, vomiting×2, sweating, dizzy(恶心、呕吐2次、出汗、眩晕) 1997:external chest tightness and dyspnea initially controlled atenolol. 1997年:出现胸外疼痛与呼吸困难，最终经服atenolol控制。 4/12 symptoms worse, exercise tolerance 200 yards on flat, limited by chest pain 4月12日，症状加重，受胸痛限制，仅耐受平地行走200码 No rest pain, no orthopnoea, no PND 无静息时疼痛，无端坐呼吸、无阵发性夜间呼吸困难 Risk factors危险因素 Hypertension-no高血压:无 Smoking-20 cigarettes per day for 16 years吸烟:16年来每天20支 Diabetes-no糖尿病:无 Cholesterol-never checked胆固醇:未查 Ischemic heart disease-angina, previous MI缺血性心脏病:心绞痛、有心肌梗死病史 PMH(past medical history)过去史 1963: appendectomy 1963年:阑尾切除手术 1972: duodenal ulcer, no symptoms since1972年:十二指肠溃疡，之后无症状 1986: myocardial infarction, full recovery / No subsequent investigation1986年: 心肌梗死，完全恢复，无随访 1989: gout quiescent on treatment1989年:痛风治疗期间症状静止 No diabetes, hypertension, rheumatic heart disease, tuberculosis, epilepsy, asthma, jaundice, cerebrovascular disease.无糖尿病、高血压、风湿性心脏病、结核病、癫痫、哮喘、黄疸、脑血管疾病 S/E(systems inquiry)系统回顾 General 一般情况 Fatigue lately, appetite unchanged, weight stable, no sweats or pruritus, sleeping well 最近有疲劳感，食欲无改变，体重稳定，无出汗或骚痒，睡眠佳。 RS呼吸系统 Dyspnea on exertion, particularly uphill, but not limiting; no cough sputum/wheeze 劳累时呼吸困难，上坡尤其如此，但无呼吸限制，无咳嗽咳痰、哮喘。 GIT gastrointestinal tract胃肠道 No current indigestion现无消化不良。 No symptoms lile previous duodenal ulcer过去无十二指肠溃疡症状。 No vomiting/dysphagia/abdominal pain无呕吐、吞咽困难、腹部疼痛。 GUS genitourinary system生殖泌尿道 No urinary systems无泌尿道症状。 NS神经系统 No headache/syncope无头痛、晕厥。 No dizziness/limb weakness/sensory loss无眩晕、肢体麻木、感觉丧失。 No disturberd bision/hearing/smell/speech无视觉、听力、味觉、嗅觉、语言障碍。 MS运动系统 No painful gout for 5 years无痛性痛风5年。 No joint pain/stiffness/swelling无关节痛、僵硬、肿胀。 No disability无伤残。 更多内容请参考医学知识网:www.hope.net.cn，增长医学知识。 Skin皮肤 No rash/pruritus/bruising无皮疹、瘙痒、青肿。 Drug history药物史 Atenolol 100 mg once daily(Atenolol 100mg每天1次) GTN as required需要服用硝酸甘油。 Not taking aspirin无服用过阿斯匹林。 Allergies: penicillin-skin rash过敏反应:青霉素――皮疹。 FH(family history)家族史 Father died of “heart attack” at age 53. 父亲53岁死于“心脏病”。 Mother died of old age at 76. 母亲于76岁去世。 SH(social history)社会史 Lives with wife who fit and well.妻子健在，与其共同生活。 Own house私宅。 Completely independent生活全部自理。 Smoking 20 cigs/day for many years多年每天抽烟20支。 Alcohol: 24 units per week饮酒:每周24个单位。 Sexual history: not appropriate性生活:未 评价 LEC评价法下载LEC评价法下载评价量规免费下载学院评价表文档下载学院评价表文档下载 。 Overseas travel: not appropriate海外旅游:未评价。 Pets: not appropriate宠物:未评价。 Occupation: heavy goods vehicle driver职业:大型货车卡车司机。 O/E(on examination)体检结果 General 一般情况 Unwell, sweaty, clammy, no cyanosis/jaundice 一般情况不佳，出汗、皮肤湿冷，无青紫、黄疸。 temperature: 37.5? 体温37.5?。 cigarette-stained fingers 烟熏手指。 no arcus / xanthomas / xanthelasma 无老人弓环、黄瘤、黄斑瘤。 CVS心血管系统 Pluse 104 bpm regular, normal character 脉搏每分钟104次，规则，心音正常。 BP110/70 mmHg (right), 112/74 mmHg (left) 血压110/70 mmHg右，112/74 mmHg左。 JVP(jugular venous pulse) normal 颈静脉博动正常。 No precordial scars /chest deformities 无心前区疤痕、胸廓畸形。 Apex beat displaced to anterior axillary’s line 6th intercostals space 心尖博动向腋前线第6肋间移位。 No parasternal heave /thrills 无胸骨旁隆起、震颤。 Auscultation: heart sounds normal, but soft pan systolic murmur at apex radiating to axilla 听诊:心音正常，但心尖问及收缩前柔和杂音，向腋窝放www.hope.net.cn。 PSM at apex and ejection systolic murmur in aortic area with no radiation 心尖问及收缩前柔和杂音，以及主动脉区喷www.hope.net.cn性收缩期杂音，无放www.hope.net.cn。 ESM in aortic area 收缩期www.hope.net.cn血杂音。 Peripheral pulses: absent right popliteal to dorsails pedis 周围脉搏:右腘窝至足背动脉博动阙如。 No sacral or ankle edema 无骶部与踝部水肿。 RS呼吸系统 Trachea central 气管居中。 Respiratory rate15/ min, no respiratory distress呼吸频率15次/分，无呼吸窘迫。 Expansion symmetrical and normal胸廓扩张对称正常。 Vocal fremitus normal 语音震颤正常。 Percussion note normal叩击音正常。 Breath sounds vesicular throughout, no added sounds全肺闻及水泡音，无额外音。 Abdomen腹部 No scars/ veins distension无疤痕、静脉怒张。 Palpation: soft, but tender LIF(left iliac fossa)扪诊:腹部柔软，但有触痛(左髂前窝)。 Percussion note normal叩击音正常。 Auscultation: bowel sounds normal听诊:肠鸣音正常。 Genitalia not examined生殖器未检查。 Rectal examination: not performed肛门检查:未检查。 NS神经系统 Higher function normal高级神经功能正常。 Cranial nerves颅神经 ?: normal第一对颅神经:正常。 ?:PERRLA(pupils equal in reaction to light and accomodation)/ normal fundi and visual fields 第二对颅神经:瞳孔对光调节反应等大，正常眼底与视野。 ?,?,?: no diplopia / nystagmus第三、四、九颅神经:无复视和眼球震颤。 ?-?: normal第五至十二对颅神经正常。 upper and lower limbs: power, tone, coordination, sensation all normal 上下肢:肌力、肌张力、协调、感觉正常。 Reflexes放Right右 Left左 www.hope.net.cn Bideps二头肌 ，， ，， Supinator旋后肌 ，， ，， Triceps三头肌 ，， ，， Knee膝盖 ，， ，， Ankle踝 ，， ，， Plantar跖 ， ， Joints and skin: Normal关节与皮肤:正常。 Summary 47-year-old male smoker with a family history and previous history of ischaemic heart disease, presents with s 4-month history of increasing exertional chest pain and a 4-hour history of persistent, severe pain at rest, which is unrelieved by GTN and associated with nausea, vomiting, and sweating. On examination, he has a resting tachycardia and evidence of left ventricular dilatation with a displaced apex beat and possible secondary mitral regurgitation. The most likely diagnosis is acute myocardial infarction. 47岁男性，有吸烟史与缺血性心脏病的家族史与过去病史，近4个月胸骨后压痛渐重，今静息时出现持续 严重疼痛4小时，硝酸甘油未能缓解，并伴有恶心、呕吐与大汗。体检发现有静息时心动过速与左心室扩 大依据，心尖搏动偏移，可能有二尖瓣返流。可能性最大的诊断是急性心肌梗死。 Problem list问题总结 1. chest pain-myocardial infarction?胸痛是否由心肌梗死引起, 2. known ischaemic heart disease- myocardial infarction, post-infarct angina已知缺血 性心脏病是否引起心肌梗死、梗死后心绞痛, 3. Clinical left ventricular enlargement with secondary mitral regurgitation? 临床上有否左心室扩大伴二尖瓣返流, 4. Previous duodenal ulcer but quiescent for years-no contraindications to thrombolysis? 十二指肠溃疡但静息多年，对溶栓疗法是否有禁忌症, 5. Gout – can be precipitated by diuretics prescribed for cardiac failure 痛风――治疗心衰的速尿可促发痛风 6. HGV driver – should he still be driving? 是否适合继续从事重型货车司机驾驶职业,