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 hospitalization or clinic visit. This could include:
Shortness of breath (main symptom)
Rapid, shallow breathing
Confusion or drowsiness
Headache
Chest tightness
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset, duration, and severity of shortness of breath
Changes in breathing pattern (increased work of breathing, use of accessory muscles)
Presence of cough (productive vs. non-productive)
Fever, chills, or other signs of infection
Recent changes in medications or medical conditions
既往史 (jì wàng shǐ) Past Medical History:
Underlying lung disease (COPD, asthma, cystic fibrosis)
Neuromuscular disorders (weakness affecting respiratory muscles)
Sleep apnea
History of smoking
Medications (current and recent) – including opioids, sedatives, diuretics
家族史 (jiā zú shǐ) Family History:
Family history of lung disease (COPD, asthma)
社会史 (shè huì shǐ) Social History:
Smoking history (significant risk factor)
Occupational exposures (dust, fumes)
查体 (chá tǐ) Physical Examination:
Vital signs:
Respiratory rate (elevated in hypercapnia)
Oxygen saturation (may be low despite increased respiratory effort)
Blood pressure
Heart rate
General appearance (respiratory distress, use of accessory muscles)
Chest exam:
Chest wall movement (use of accessory muscles)
Breath sounds (diminished or wheezing)
Percussion (dullness may indicate pneumonia)
Neurologic exam:
Mental status (confusion, lethargy, asterixis – flapping tremor)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Arterial blood gas (ABG): confirms hypercapnia (elevated PaCO2) and may show respiratory acidosis (low pH)
Basic metabolic panel (electrolytes, kidney function) – to assess for potential complications
Complete blood count (CBC) – may show elevated white blood cells if infection is present
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Chest X-ray: may show signs of underlying lung disease (pneumonia, COPD)
Chest CT scan (if chest X-ray inconclusive or complex case)
诊断 (zhěn duàn) Diagnosis:
Hypercapnic respiratory failure (acute or chronic)
Acute on chronic respiratory failure (if superimposed acute illness on underlying chronic lung disease)
Underlying cause of respiratory failure (e.g., COPD exacerbation, pneumonia, neuromuscular disease)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Supportive care:
Oxygen therapy (to maintain adequate oxygen saturation)
Non-invasive ventilation (e.g., BiPAP) – may be needed to support breathing
Medications:
Bronchodilators (for COPD or asthma)
Antibiotics (if infection is present)
Diuretics (if fluid overload contributes to respiratory failure)
Nebulized treatments (bronchodilators, mucolytics) – if indicated
Treatment of the underlying cause (e.g., antibiotics for pneumonia, medication adjustments for COPD)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of hypercapnia, underlying lung disease, and response to treatment.
Hypercapnic respiratory failure can be a life-threatening condition, but early intervention and treatment can improve outcomes.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of smoking cessation (if applicable)
Proper use of oxygen therapy (if prescribed)
Early recognition of signs of worsening respiratory function
Importance of medication adherence for underlying lung disease
Pulmonary rehabilitation (exercises to improve breathing function) – if appropriate
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of illness and response to treatment.
Close monitoring of respiratory function and blood gases is essential.
Follow-up appointments to manage underlying lung disease and prevent future episodes