Transcript 入院录写作

Overview
Admission Note
入院录写作概述
杨明山
Classification of Medical Writing
Admission Note
Medical
Literature
Medical
Record
Classification of Medical Writing
 MIAs abstract
 IMRAD paper
 Systematic
Review
 General Medical
Record (History)
 Admission Note
 Daily Record
 Discharge Note
Admission Note
Clinical Record
POMR
Problem-oriented Medical Record
Lawrence Weed. MD.
 1947: Columbia
University
 ？: Yale
University School
of Medicine
 1964: “Medical
records, patient
care, and medical
education”
Problems List
Problem
No.
Active
Problem
#1
Acute
peritonitis
Onset Inactive Problem
Date
Date
Resolved
14/7
17/7
#2
Cholecystectomy
Oct/70
#3
hypertension
controlled
Medical Writing Series
4.20 method
(Admission Note)
入院录
廿句写作法
Chief Complaint
Section One
Chief Complaint
Section One
Only 1 sentence
第1句 – 主诉 - 写作分析
A 25 year-old lady
was admitted to this hospital
on May 11, 2003
because of fever and cough
with chill
for three days.
个人资料
被动，过去
入院日期
主诉
次要
持续时间
第1句 – 介词妙用 – 主诉
 A 25 year-old ladywas
admitted to1 this hospital on2
May 11, 2003 because of3 fever
and cough with4 chill for5 three
days.
Histories
Section Two
Histories
Section Two
Current History
第2句 – 起病写作分析
Four days ago,
the patient took a trip to
Guangzhou on business.
时间状语
起病
原因
第3句 – 演变写作分析
Next morning
状语
she had chill and malaise,
and in the afternoon
began to cough and
temperature went up to
38℃ .
状语
演变
第4句 – 经治写作分析
Self administration
of APC and Dicough
had no effect.
经治经过
药物
效果
第4句 - 其他表达
home medication
customary medication
outpatient medications
No treatment
第4句 – 经治效果表达
药物
人
ineffective
动物 be unresponsive
症状
体征
病症
to 干预
without improvement, effectiveness
第5句 – 状态写作分析 – 无特殊
The patient was
in good nutritional and
conscious condition (of)
on admission
状态
入院时
现病史写作关键：time adverbial









点：Since the initial diagnosis, …….
时刻：……. at approximately 5 a.m.
小时：Several hours after these symptoms, …..
半天：That afternoon …….
天：On the fifth hospital day ……..
天：On hospital day 5 …….
周：Over the next week …….
月：Two months prior to admission, …….
年：One year ago …….
Histories
Section Two
Other Histories
第6句 – 过去病史写作分析
The patient has been healthy
a week prior to admission
and had no special diseases
previously
including pneumococcal
pneumonia and TB and
现病多久
完成态
过去史
过去式
Family, Personal, Ob/Gyn (Childbearing) H.
 Customary medications were xx.
 His only medication was xx for xx.
 P did not smoke and rarely consumed




alcohol.
P had a x-pack-year smoking history
There was a (no) family history of xx.
Parents are alive and well.
P died of x at the age of
第7句 – 家族史写作分析
There was
no family history (of xx)
concerned .
存在句
万能句
Examinations
Section Three
第8句 – 生命体征写作分析
Body temperature was 38.4℃, respiration
rate was 30/min, pulse rate was 104 b/min,
and BP was 108/72mmHg.
His vital signs are
body temperature 38.4℃,
respiration rate 30/min,
pulse rate 104 b/min,
and BP 108/72mmHg.
第9句 – 望诊写作分析
She
was found
seen
observed to be slightly dyspnea.
recognized
detected
visible
望诊
被动
第9句 – 望诊写作要求
① 部位: Vigorous small intestinal peristalsis
can be seen in the center of the abdomen.
② 时间: Symmetrical distension is seen when
intra-abdominal content is increased.
③ 特征: An enlarged uterus was seen as a
central rounded suprapubic swelling.
④ 病理: Paralytic ileus is seen in patients
after abdominal surgery.
第10句 – 叩诊听诊写作分析
The right lower posterior chest
showed
dullness
on percussion
with moist rales
at the end of inspiration
on auscultation.
叩诊
主动
阳性
方式
听诊
时间
方式
第10句 – 触诊表达
 To be palpated；To be felt
 部位：Small masses (nodules) are felt
near the uterus or in the cul-de-sac.
 时间: No fibroids are felt during the
bimanual pelvic or rectal exams.
 特征: His neurologic exam
demonstrated mild generalized
hypotonia
第10句 – 叩诊表达
 To be heard；tap, strike, flick, Percuss
① 部 位 : These sounds are heard only over the
bronchi and trachea.
② 时间: Friction was heard in both inspiration and
expiration.
③ 特征: The cancerous area was felt as a hard,
irregular nodule.
④ 病理: It is heard in bronchiectatic cavities or
pneumothorax.
第10句 – 听诊表达
① location：
A soft, high-pitched, holosystolic blowing
murmur is heard in the mitral area.
② time：
A murmur can be heard during the diastole.
③ feature
His lungs were clear to auscultation.
④ other
An aortic murmur is heard with the patient
sitting forward in full expiration.
第10句 四诊句型-介词短语
 On physical examination, …
 A tapping apex beat may be apparent
on inspection. (最多）
 Ill-defined nodule margins by palpation
 The nodule was evident at palpation
第11句 – 辅助检查写作分析
X-ray films of the chest over
showed
cloudy patches
both lower lungs in the posterioranterior view and the lateral view.
项目
主动
特征
部位
方式
Imaging, Ultrasound and Others
 Doppler studies revealed normal blood
flow to both ovaries.
 A friable lesion 15 to 20 mm in diameter
was identified very low in the rectum.
 During a digital rectal examination, a
mobile, soft mass was found low in the
left rectum.
⒂ Imaging, Ultrasound and Others
 Pattern
 Exam showed …
 The liver was shown to be enlarged…
 The heart murmur was heard …
 检查项目作主语：主动态
 阳性体征作主语：被动态
 人的器官作主语：被动态
第12句 – 实验写作分析
The white blood cell count
was
10.0 x 109/L (8,000/cu mm).
项目
主系表
第12句 – lab 表达 - Same




Item was normal.
Item was positive
Item was negative
Item was number
 A serologic test for antibody to Helicobacter
pylori was positive.
 The urine was positive for ketones (++).
 The uterine volume appeared normal.
 A stool specimen was negative for occult blood.
第13句 – 采样写作分析
And the blood
has been sampled
for
liver function, kidney function,
arterial gas analysis as well as PCR
标本
完成
项目
第14句 – 写作分析 – 回报
Those lab reports
haven’t
arrived.
returned.
come back.
been back.
完成时态
Universal There-be 万能句
 Current History:





On the sixth day, there was an episode of bradycardia
and vomiting
Previous Hisroty:
There was no history of sexually transmitted disease.
Inspection
There was swelling in one rear “ankle” as well.
Palpation
There was a large hard irregular mass in the
abdomen.
Percusion
There was a minimal corneal reflex in the left eye.
Ausculation
There were scattered rales and rhonchi all over the
lung fields.
Approach
Section Four
第15句 – 正文 – 诊断
 Our impression
of the case
would be severe
acute respiratory
syndrome.
第15句 – 诊断写作分析
Our impression of the case.
Our tentative diagnosis
Our initial diagnosis
would be
severe acute respiratory
syndrome
诊断
虚拟
主要诊断
第16句 – 治疗写作分析
On the day of admission,
the patient
was given
时间
过去；停用
第16句 – 治疗其他表达
 Xx given
 Xx prescribed
 Xx instituted
 Xx was
administered
 administered
 taken orally
 injected
 infused
intravenously,
intramuscularly,
by TPN
第17句 – 写作分析
Oxygen and CPAP
have been
applied.
完成
应用至今
第18句 – 当前问题写作分析
However
the patient’s temperature
is still going on
and dyspnea
tends to be
more severe.
当前问题
将来表达
第19句 – 写作分析
The patient
will be given
tracheostomy
in case of emergency.
计划
治疗
将来时间
第20句 – 写作分析
And meanwhile the patient
will be given
将来
prednisolone
双刃剑
when the patient develops
状语从句
the early sign of respiratory
failure
or if infiltrate patch is over one 条件从句
third of the both lung fields.
诊疗
计划
一般
将来时
will be
given
入院: 一般过去 - was given
至今: 现在完成 - has been given
目前: 现在进行 - is being given
将来: 一般将来 - will be given
条件状语
短语,从句
in case of
emergency
时间状语
短语,从句
when the
patient
develops sth.
Summary
C. 4-section
1. Personal details （个人资料）
2. Admission date（入院日期
主诉
3. Major complaint（主诉）
4. Present history（现病史）
病史
5. previous & other histories（过去病史等）
6. Physical examination done（体检）
检查
7. Laboratory done（实验室检查）
8. Impression（印象）
9. Problems （问题列单）
处理
10. Initial plan for treatment（初步处理）
病史汇报
廿点写作法
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Four days ago,.
A 25 year-old lady was admitted to
The next day she complained of
Self administration of
The patient was in good
The patient has been
Physical examination on admission:
Body temperature (was)
And she was found
The right lower posterior chest
showed
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
X-ray films of the chest showed
The white blood cell count
And the blood has been sampled
Those lab reports haven’t arrived.
Our impression of the case would be
On the day of admission,
Oxygen and CPAP
However the patient’s temperature is
The patient will be given
And meanwhile the patient will be
given
The Marriage of Figaro - Overture
(1786)
The case presentation based
on the admission note is the
overture of the Medical
bilingual education
I wish you would be a new
generation of clinicians with
bilingual capability.
THANK YOU