入院录写作.pptx

Classification of Medical Writing Medical LiteratureMedical RecordAdmission NoteClassification of Medical Writing MIAs abstractIMRAD paperSystematic ReviewGeneral Medical Record(History)Admission NoteDaily RecordDischarge NoteAdmission NoteClinical RecordPOMRProblem-oriented Medical RecordLawrence Weed.MD.1947:Columbia University？:Yale University School of Medicine1964:“Medical records,patient care,and medical education”Problems ListProblemProblemNo.No.Active Active ProblemProblemOnset Onset DateDateInactive ProblemInactive ProblemDate Date ResolvedResolved#1Acute peritonitis14/717/7#2#2Cholecys-Cholecys-tectomytectomyOct/70Oct/70#3#3hypertensionhypertensioncontrolledcontrolled(Admission NoteAdmission Note)Medical Writing Series4.204.20 methodmethod入院录入院录廿句写作法廿句写作法Chief ComplaintSection OneChief ComplaintSection OneOnly 1 sentence第第1句句 主诉主诉-写作分析写作分析A 25 year-old lady个人资料was admitted to this hospital 被动，过去on May 11,2003入院日期because of fever and cough主诉with chill次要for three days.持续时间第第1句句 介词妙用介词妙用 主诉主诉 A 25 year-old ladywas admitted to1 this hospital on2 May 11,2003 because of3 fever and cough with4 chill for5 three days.HistoriesSection TwoHistoriesSection TwoCurrent History 第第2句句 起病起病写作分析写作分析Four days ago,时间状语the patient took a trip to Guangzhou on business.起病原因第第3句句 演变演变写作分析写作分析Next morning 状语she had chill and malaise,and in the afternoon 状语began to cough and temperature went up to 38.演变第第4句句 经治经治写作分析写作分析Self administration 经治经过of APC and Dicough 药物had no effect.效果第第4句句-其他表达其他表达home medication customary medicationoutpatient medicationsNo treatment药物beineffectiveto病症人unresponsive干预动物症状体征without improvement,effectiveness第第4句句 经治经治效果效果表达表达第第5句句 状态状态写作分析写作分析 无特殊无特殊The patient was in good nutritional and conscious condition(of)状态on admission入院时现病史写作关键：现病史写作关键：time adverbial 点：点：Since Since the initial diagnosis,.the initial diagnosis,.时刻：时刻：.at approximately.at approximately 5 5 a.m.a.m.小时：小时：Several Several hourshours after these symptoms,.after these symptoms,.半天：半天：That That afternoonafternoon.天：天：On the fifth hospital On the fifth hospital dayday.天：天：On hospital On hospital dayday 5.5.周：周：Over the next Over the next week week.月：月：Two Two monthsmonths prior to admission,.prior to admission,.年：年：One One yearyear ago.ago.HistoriesSection Two Other Histories 第第6句句 过去病史写作分析过去病史写作分析The patient has been healthy 现病多久完成态a week prior to admission and had no special diseases previously 过去史过去式including pneumococcal pneumonia and TB and 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 historyThere was a(no)family history of xx.Parents are alive and well.P died of x at the age of第第7句句 家族史写作分析家族史写作分析There was 存在句万能句no family history(of xx)concerned.ExaminationsSection Three第第8句句 生命体征生命体征写作分析写作分析Body temperature was 38.4,respiration rate was 30/min,pulse rate was 104 b/min,and BP was 108/72mmHg.His vital signs arebody temperature 38.4,respiration rate 30/min,pulse rate 104 b/min,and BP 108/72mmHg.第第9句句 望诊望诊写作分析写作分析She望诊was foundto be slightly dyspnea.被动被动seenobservedrecognized detectedvisible第第9句句 望诊望诊写作要求写作要求部部位位:Vigorous small intestinal peristalsis can be seen in the center of the abdomen.时时间间:Symmetrical distension is seen when intra-abdominal content is increased.特特征征:An enlarged uterus was seen as a central rounded suprapubic swelling.病病理理:Paralytic ileus is seen in patients after abdominal surgery.第第10句句 叩诊听诊叩诊听诊写作分析写作分析The right lower posterior chest叩诊showed主动dullness阳性on percussion方式with moist rales听诊at the end of inspiration时间on auscultation.方式第第10句句 触诊表达触诊表达 To be palpated；To be felt部位：Small masses(nodules)are felt near the uterus or in the cul-de-sac.时时间间:No fibroids are felt during the bimanual pelvic or rectal exams.特征:His neurologic exam demonstrated mild generalized hypotonia第第10句句 叩诊表达叩诊表达 To be heardTo be heard；tap,strike,flick,Percusstap,strike,flick,Percuss部部位位:These These sounds sounds are are heard heard only only over over the the bronchi and trachea.bronchi and trachea.时时间间:Friction Friction was was heard heard in in both both inspiration inspiration and and expiration.expiration.特特特特征征征征:The The cancerous cancerous area area was was felt felt as as a a hard,hard,irregular nodule.irregular nodule.病病理理:It is heard in bronchiectatic cavities or pneumothorax.第第10句句 听诊表达听诊表达 locationlocation：A A soft,soft,high-pitched,high-pitched,holosystolic holosystolic blowing blowing murmur is heard in the mitral area.murmur is heard in the mitral area.timetime：A murmur can be heard during the diastole.A murmur can be heard during the diastole.featurefeature His lungs were clear to auscultation.His lungs were clear to auscultation.otherother An An aortic aortic murmur murmur is is heard heard with with the the patient patient sitting forward in full expiration.sitting forward in full expiration.第第10句句 四诊句型四诊句型-介词短语介词短语On physical examination,A tapping apex beat may be apparent on inspection.(最多）最多）Ill-defined nodule margins by palpation The nodule was evident at palpation第第11句句 辅助检查写作分析辅助检查写作分析X-ray films of the chest over项目showed主动cloudy patches特征both lower lungs in the posterior-anterior view and the lateral view.部位方式Imaging,Ultrasound and OthersDoppler 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.Imaging,Ultrasound and OthersPatternExam showed The liver was shown to be enlargedThe 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：被动态第第12句句 实验写作分析实验写作分析The white blood cell count项目was主系表10.0 x 109/L(8,000/cu mm).第第12句句 lab 表达表达-SameItem was Item was normal.normal.Item Item was positivepositiveItem Item was negativenegativeItem Item was numbernumberA A serologic serologic test test for for antibody antibody to to Helicobacter Helicobacter pylori was positive.pylori was positive.The urine was positive for ketones(+).The urine was positive for ketones(+).The uterine volume appeared normal.The uterine volume appeared normal.A stool specimen was negative for occult blood.A stool specimen was negative for occult blood.第第13句句 采样写作分析采样写作分析And the blood标本has been sampled完成forliver function,kidney function,arterial gas analysis as well as PCR项目第第14句句 写作分析写作分析 回报回报Those lab reportshavent arrived.完成时态e back.been back.Universal There-be 万能句万能句Current History:Current History:On On the the sixth sixth day,day,there there waswas an an episode episode of of bradycardia bradycardia and vomitingand vomitingPrevious Hisroty:Previous Hisroty:There was There was no history of sexually transmitted disease.no history of sexually transmitted disease.InspectionInspection There was There was swelling in one rear“ankle”as well.swelling in one rear“ankle”as well.PalpationPalpation There There waswas a a large large hard hard irregular irregular mass mass in in the the abdomen.abdomen.PercusionPercusion There was There was a minimal corneal reflex in the left eye.a minimal corneal reflex in the left eye.AusculationAusculation There There werewere scattered scattered rales rales and and rhonchi rhonchi all all over over the the lung fields.lung fields.ApproachSection Four第第15句句 正文正文 诊断诊断Our impression Our impression of the case of the case would be severe would be severe acute respiratory acute respiratory syndrome.syndrome.第第15句句 诊断写作分析诊断写作分析Our impression of the case.诊断Our tentative diagnosisOur initial diagnosiswould be虚拟severe acute respiratory syndrome主要诊断第第16句句 治疗写作分析治疗写作分析On the day of admission,时间the patientwas given过去；停用第第16句句 治疗其他表达治疗其他表达Xx givenXx prescribedXx institutedXx was administeredadministered taken orallyinjectedinfused intravenously,intramuscularly,by TPN第第17句句 写作分析写作分析Oxygen and CPAPhave been完成applied.应用至今第第18句句 当前问题写作分析当前问题写作分析Howeverthe patients temperatureis still going on当前问题and dyspneatends to be将来表达more severe.第第19句句 写作分析写作分析The patientwill be given计划tracheostomy治疗in case of emergency.将来时间第第20句句 写作分析写作分析And meanwhile the patientwill be given将来prednisolone双刃剑when the patient develops状语从句the early sign of respiratory failureor if infiltrate patch is over one third of the both lung fields.条件从句诊疗诊疗计划计划一般将来时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.入院入院入院入院:一般过去一般过去一般过去一般过去 -was-was given given至今至今至今至今:现在完成现在完成现在完成现在完成 -has beenhas been given given目前目前目前目前:现在进行现在进行现在进行现在进行 -is beingis being given given将来将来将来将来:一般将来一般将来一般将来一般将来 -will bewill be given givenSummaryC.4-section 1.Personal details Personal details（个人资料）（个人资料）2.Admission dateAdmission date（入院日期（入院日期3.Major complaintMajor complaint（主诉）（主诉）4.Present historyPresent history（现病史）（现病史）5.previous&other historiesprevious&other histories（过去病史等）（过去病史等）6.Physical examination donePhysical examination done（体检）（体检）7.Laboratory doneLaboratory done（实验室检查）（实验室检查）8.ImpressionImpression（印象）（印象）9.Problems Problems（问题列单）（问题列单）10.Initial plan for treatmentInitial plan for treatment（初步处理）（初步处理）病史病史病史病史检查检查检查检查处理处理处理处理主诉主诉主诉主诉病史汇报病史汇报廿点写作法廿点写作法1.1.Four days ago,.2.2.A 25 year-old lady was admitted to3.3.The next day she complained of 4.4.Self administration of5.5.The patient was in good6.6.The patient has been7.7.Physical examination on admission:8.8.Body temperature(was)9.9.And she was found10.10.The right lower posterior chest showed11.11.X-ray films of the chest showed 12.12.The white blood cell count 13.13.And the blood has been sampled14.14.Those lab reports havent arrived.15.15.Our impression of the case would be 16.16.On the day of admission,17.17.Oxygen and CPAP18.18.However the patients temperature is 19.19.The patient will be given20.20.And meanwhile the patient will be givenThe 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