心绞痛英文病历.doc

Sample History and Physical Note Charting Plus? - Electronic Medical Records Note for Jane Doe on 4/4/03 - Chart 5407 Chief 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 radiating to the arm and pain radiating to the jaw. Context: The patient has had no previous treatments for this condition. Duration: Condition has existed for 5 hours. Quality: Quality of the pain is described by the patient as crushing. Severity: Severity of condition is severe and unchanged. Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patients elevated cholesterol is not being treated with medication. Menopause occurred at age 53. Allergies: No known medical allergies. Medication History: Patient is currently taking Estraderm 0.05 mg/day transdermal patch. PMH: Past medical history 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 attack associated with father (deceased). ROS: Unremarkable with exception of chief complaint. General: Patient is a 62 year old female who appears pleasant, her given age, well developed, oriented, well nourished, alert and moderately overweight. Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs. HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the to