Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: Briefly describe the patient’s main reason for concern. This could include:
Fever, chills
New or worsening cough
Shortness of breath
Productive cough (痰液 (tán yè) – sputum production) – color and consistency may be noted
Pleuritic chest pain (sharp pain with breathing)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms
Severity of symptoms (e.g., cough frequency, shortness of breath at rest or with exertion)
Presence of productive cough – characteristics of sputum (color, amount, purulence)
Recent hospital admission and length of stay
Underlying medical conditions (e.g., chronic obstructive pulmonary disease (COPD), heart failure, diabetes)
Prior antibiotic use (recent and within the past 90 days)
Recent procedures or surgeries (especially those involving the respiratory tract)
既往史 (jì wàng shǐ) Past Medical History:
History of pneumonia or other respiratory infections
Immunosuppression (medications, chronic illnesses)
Smoking history (significant risk factor)
Aspiration risk factors (dysphagia, recent stroke)
家族史 (jiā zú shǐ) Family History:
Not typically relevant for HAP, but inquire about history of tuberculosis (TB) in close contacts
社会史 (shè huì shǐ) Social History:
Living situation (hospitalized, rehabilitation facility, home)
Exposure to environmental hazards (dust, smoke)
查体 (chá tǐ) Physical Examination:
Vital signs (temperature, respiratory rate, oxygen saturation)
General appearance (illness, respiratory distress)
Respiratory exam:
Chest auscultation (rales, crackles, wheezing)
Decreased breath sounds over affected area
Use of accessory muscles for breathing
Oxygen saturation on room air and with supplemental oxygen (if needed)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) – may show elevated white blood cells
Electrolytes – to assess dehydration
Sputum culture and sensitivities – to identify causative organism and guide antibiotic selection
Blood cultures (if high clinical suspicion)
Chest X-ray – may show infiltrates (areas of inflammation) in the lungs
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Chest X-ray is usually sufficient for initial diagnosis.
Chest CT scan (may be considered in complex cases or if X-ray inconclusive)
诊断 (zhěn duàn) Diagnosis:
Hospital-acquired pneumonia (HAP)
Community-acquired pneumonia (CAP) – if pneumonia symptoms developed prior to hospitalization
Specify suspected causative organism based on clinical presentation, chest X-ray, and sputum Gram stain (if available)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Empiric antibiotic therapy based on local resistance patterns and suspected organism
Antibiotic selection may be adjusted based on culture and sensitivity results
Respiratory support (oxygen therapy, nebulized treatments)
Supportive care (fluids, pain management)
预后 (yù hòu) Prognosis:
Discuss the outlook based on severity of illness, underlying medical conditions, and response to treatment.
Hospital-acquired pneumonia can be a serious complication, and early diagnosis and treatment are crucial.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of hand hygiene to prevent the spread of infection
Deep breathing exercises and incentive spirometry to improve lung function
Smoking cessation (if applicable)
Warning signs of worsening respiratory symptoms
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment to monitor response to treatment, assess for complications, and potentially adjust antibiotics based on culture results.