医学英语出院小结.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Medical English,Writing,Clinical Reports,Aims for Students,To know the format of the discharge summaries;,To understand the language features of the discharge summaries;,To master the special language structures of the discharge summaries;,To know how to write a discharge summary.,Clinical Reports,1.Radiology Reports,2.Operative Reports,3.Discharge Summaries,4.Consultation(,a meeting with an expert or professional,such as a medical doctor,in order to seek advice,),5.Autopsy Reports,A discharge summary is a clinical report prepared by medical or mental health practitioners when a patient is ready for discharge from a hospital or care facility.,The discharge summary informs outpatient medical or mental health workers about services provided by the inpatient facility:,admitting complaint,diagnoses,medications,treatments,and recommendations for outpatient follow-up services.,The discharge summary should include all information pertinent to the ongoing treatment of the patient and the patients condition.,Discharge Summaries,1.Presenting illness,1.1.Language Features,In this part,the general condition,the diseases and the treatment are described in,past tense,.,E.g.,The patient is a 66-year-old white male who,was,admitted for adenocarcinoma(,腺癌）,of the esophagogastric junction,with extension to esophagus,and periaortic nodes.,1.Presenting illness,adeno+carcinoma,1.2.Special Language Structures,1).,This was the second hospital admission for,this 50-year-old white female,with,approximately a 25 year history of intermittent and recently progressive asthma.,occurring at irregular intervals;not continuous or steady,1.Presenting illness,2.Past medical history,2.1.Language Features,In this part,the general condition of the patient is reviewed with a few words.,E.g.,Medications:None,Allergies:None,Illnesses:Tuberculosis in the 1930s.,2.Past medical history,2.2.Special Language Structures,1)She,had,pneumonia 25 years,ago,and,had,an episode of esophageal spasm 6 years,ago,.,英,i:sfdi:l,美,isfdil,食道痉挛,E.g.,The 55-year-old female patient,underwent,esophagogatrectomy,omentectomy,，,and pyloroplasty(,幽门成形术,)in March of this year.,pylorospasm:,幽门痉挛,2.Past medical history,omentum:,网膜,网膜切除术,pail:r,plsti,Pylorus-,幽门,Exe.,姓名：,J.K.,性别：女 年龄：,83,职业：退休护士,病人长期患有高血压，以利尿剂（,diuretic,）治疗效果良好。入院前连续,12,个小时在胸骨下部（,substernal,）感觉到“像牙疼一样的”疼痛。,Present illness:,J.K.a 83-year-old retired nurse,was admitted to hospital with a chief complaint of substernal“toothache-like”chest pain of 12 hours duration.,Past Medical History:,She has a long history of hypertension that was previously well controlled with diuretic.,3.Physical examination,3.1.Language Features,A brief statement of the results of the physical examination is presented.Therefore,noun phrases and short sentences with simple present tenses,are used.,3.2.Special Language Structures,1)(name of the organ):manifestation(noun phrases),e.g.,HEART:Normal sinus rhythm,no rubs,murmurs or gallops.,3.Physical examination,2)noun+adj.,E.g.,Bowel sounds active.,3.Physical examination,4.1.Language Features,This part presents the data on admission and at discharge with,noun phrases,and,short sentences,.,4.Laboratory data,Electrocardiograph,E.g.1 On admission,hematocrit(,血细胞比容）,38%,，,sodium 140,potassium 2.8.Chext x-rays:no infiltrates(,渗入物,).EKG:a few PVCs seen.No obvious ischemia.,premature ventricular contraction,室性早搏,E.g.2,Chest x-ray was negative.Electrocardiogram was normal.Sodium 138,potassim 5.2,chloride 104,glucose 111.Urinalysis negative.Hemoglobin(,血红素）,14.8,hematocrit 43.5,white blood cell count 15,000,platelet count 17,000.,4.Laboratory data,4.2.Special Language Structures,1,）,item+number,译：血细胞比容,43.7%,。尿常规：白细胞,6-8/,hpf,。,Hematocrit 43.7%.Rountine urinalysis 6 to 8 white blood cells/hpf.,2)item+adj./prep.,译：,电解质正常。心电图检查未见异常。胸片未见异常。,Electrolytes within normal limits.EKG normal.Chest x-rays normal.,4.Laboratory data,per high-power field(,显微镜的,),每高倍视野,E.g.,The patient was promptly resuscitated with 8 units of Plasmanate,（人血浆蛋白制剂）,with additional administration of Sodium Bicarbonate,（碳酸氢钠）,Solu-Cortef(,琥珀酸氢化可的松），,Gentamicin(,庆大霉素）,and Keflin(,头孢噻吩钠,).His blood pressure transiently rose up to 110/70.While still in the Emergency Room,he then suffered a respiratory arrest,5.Hospital Course,CPR(cardiopulmonary resuscitation),心肺复苏法,呼吸停止（,apnea,）,5.2.Special Language Structures,1)This patient,was admitted to the hospital for,the procedure.,2)The patient,tolerated the procedure well,.,3),On,her first,hospital day,the patient,was taken to,the operating room,where,she was subjected to,5.Hospital Course,4),Postoperatively,the patient did quite good.,5)The patient,was placed on.and treated with.,6),She complained of,some difficulty urinating,but urine output was quite good.,7)She,was discharged on her 14th hospital day,in good condition.,5.Hospital Course,Language Features,This part describe the conclusions of diagnosis with,noun phrases,.,e.g.,6.Discharge diagnosis,劳力型心绞痛,导管插入,(,术,),主动脉瓣狭窄,心肌血管重建术,血小板减少（症）,二尖瓣和三尖瓣返流,高脂血症,Several noun phrases are applied here.,E.g.,Prednisoen,80mg.,q.d,(each day),Digoxin,0.25mg.,q.d,7.Discharge medications,药,强的松（肾上腺皮质激素）,药,地高辛；,药,异羟基洋地黄毒苷原,The End!,