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在上一期的「出国交换前的充电」中，我们总结了英文病历中常见的缩写。话说小编呕心沥血钻研缩写、终于看懂病历之后，油然而生一种成为人生赢家的成就感。当组里的住院医笑眯眯地问小编「Would you like to present a patient ?」时，小编欣然答应，并且天真地以为，既然「present a patient 」翻译作「报病历 」，那不就是查房时把病历读一遍吗？于是第2天查房，小编读得不亦乐乎，然而组里其他人却听得哭笑不得，此时小编的心理阴影面积是正无穷的，并再次化悲愤为力量，开始学习报病历的技巧…… 对于昨日新收的病人和住院若干日的「老病人 」，报病历时很大不同，前者相对复杂，故我们先来探讨后者。报「老病人 」的病历通常包括以下部分： ※ 简要介绍 ☆ 内科：一般用一句话介绍患者的性别、年龄、重要既往/个人史、主诉 / 诊断。 eg：XX is a 40 year-old female with history of hypertension, diabetes type 2 and hyperlipidemia who was admitted for chest pain. ☆手术科室术后患者，还需说明手术和术后天数。 eg：XX is a 28 year-old male active smoker with history of alcohol abuse who was admitted for splenic rupture after car crash and is on postoperative day 3 from an open splenectomy. ※ 过去24小时的变化 主要包括以下内容： ☆ 患者病情的变化及相应处理： eg: He vomitted large amount of brown fecal fluid this morning. His abdomen was distended with noble protusion of stomach when examined. A nasogastric tube was placed and 1L fecal matter was drained. Tube feeding thus stopped.（患者今晨呕吐大量棕色粪便样液体，查体可见腹部膨隆和胃型。我们放置了鼻胃管，可见1L粪便样液体引出，暂停鼻饲。） ☆ 治疗方案的调整及患者对此的反应： eg：FiO2 was weaned down to 40% yesterday and SpO2 was stable at 100%, ABG this morning was 7.38/37/98/23.1. ☆ 重要的检验、检查结果：注意此处仅提及与病情变化或下一步治疗相关的重要结果，常规检查可不提。 eg: Abdominal CT showed left subdiaphragmatic fluid collection and pancreatic leak cannot be excluded. We will consult general surgery for further treatment. (腹部CT示左膈下液体积聚，胰瘘不除外，考虑请基本外科会诊） ☆会诊意见： eg：Endocrinology consult decided to increase lantus（来得时） to 7U Qn and blood glucose this morning was 70mg/dl. ※ 生命体征、出入量、体重变化 这里句式相对比较固定： Running his/her board: His Tmax was …, T current … HR in sinus rhythm, range between … BP via cuff ranges from …, max has been in the 80' He’s saturating 95% on 50% of FiO2 His ins and outs over the last 24 hours: He had .. in and ... out，net was ...: In has all been iv Of his outs, he had … for urine, … from drainage tube. He is …kg this morning from …yesterday. ※ 查体： 一般只描述阳性体征和重点关注的体征，可以「When I saw him/her this morning,…… 」的句式开头。 对于通路和引流管较多的患者需要描述各管路。 eg: She has a left intrajugular central line, a small bowl feeding tube, a chest tube on water seal and a foley tube. ※ 检验、检查： 主要关注异常结果和重点关注的项目，常用句式包括： … was downtrended / went down to … from …yesterday. … was as low as …, which has already been repleted. … stabilize at … … was shown on CXR, likely to be … MRI demonstrated …， either … or …cannot be excluded. ※ 用药： 一般由药剂师读药物剂量，少数情况也需要自己读，句式可灵活些： He received … units of RBC yesterday morning She is ordered for … He's currently written on ... He's on ..., which can be discontinued. He's on … drip at …mg/hr He's also on ... boluses She was given the once dose of … She had additional 2L of boluses She had … PRN and received … in total yesterday. ※ 诊疗计划： 这是小编受到震撼最深的一部分，在美国顶尖的医学院，住院医、甚至医学生报病历时都会说明自己详细的诊疗计划，具体到药物剂量的调整，然后全组会进行激烈的讨论，最终确定治疗方案，这是查房中最耗时、最教学、最锻炼人的环节。 经典的诊疗计划多是以某一症状或临床问题为核心，描述自己对该问题的判断及依据，并给出处理方案。 eg: In terms of fluid balance（问题）, he is hypervolumic（判断）. His net was +700ml yesterday，he had rale in the base bilaterally and increased lung markngs were shown on CXR, likely to be pulmonary edema（依据）. Thus, we will give him lasix （呋塞米）20 bid iv and monitor his Cr，his net goal today is -500~-1000ml（处理方式）. 其他常用句式： We can stop .. and put him on ... We can discontinue the … We can wean … down to … I'm not sure if he'll benefit from... I don't he is still in need of ... We'll keep him on... We‘ll check / order / consult... ... can be switched to iv from po. If it looks like …, we can go down / up a little bit. … is on hold given … We consider… once … ※ 新病人： 对于昨日新收的病人，框架上略有不同，需按照入院记录的顺序汇报，依次为现病史（HPI）、既往史（PMH）、手术史（PSH）、用药史（home medication)、过敏史（allergy）、个人史（social history）、家族史（family history）、系统回顾（ROS）、查体（PE）、诊疗计划（acessment and plan）。其中后几部分的表述与上文所讲报「老病人 」的病历类似，不再赘述，重点关注现病史部分。 现病史的首句与上文所讲的报「老病人 」病历的开头类似，同样是「性别、年龄、重要既往/个人史、主诉 / 诊断 」。之后会按照时间顺序讲述患者起病以来的「故事 」，包括重要的阳性症状、伴随症状，以及重要的阴性症状，常用句式包括： He first noted ……，at the same time he also developed …… Over …… weeks，his ……progressed rapidly. He reported concurrently worsening ……, as well as …… He denied …… There is no change to his …… 现病史的第二段会叙述患者在家庭医生或急诊时的症状、生命体征、查体和重要检查检验结果，并简述诊疗经过。常用句式包括： ……,which prompted him to ER ……(findings) was concerning for …… He underwent …… (procedure) …… was ordered to exclude …… …… was well-controlled by ……(drugs) He was found to be positive for…… 虽然讲了满篇的定式，但其实所谓句式、框架都不是最重要的。于是特别想分享一段经历： 交换最初几天组里其他人关于诊疗计划的讨论小编完全听不懂，却又不敢暴露，只能不懂装懂。某日主治犀利地问小编是否听懂了，小编犹豫地点头又摇头。主治意味深长地说：「你现在是医学生，母语也不是英语，所以没有人对你有要求，你可以随意问任何问题，千万不要一直含糊不清，等到你到了我这个年资，再问问题会更加尴尬」。 所以，交换期间最重要的是坦然面对自己的不足，敢想、敢说、敢问、敢做自己吧！ 精选每日一题 更多精选题可回顾历史推送文末 女，64 岁。2 型糖尿病病史 10 年，近 2 个月出现双下肢水肿。查体：BP 140/100 mmHg，神志清楚，营养差，甲状腺无肿大，双肺未闻及干、湿啰音，心率 70 次/分，律齐，肝脾未触及，双下肢明显水肿。实验室检查：空腹血糖 9.6 mmol/L，血清胆固醇 7.6 mmol/L，低密度脂蛋白胆固醇 4.6 mmol/L，血浆白蛋白 28g/L。 题目来源：硕士研究生入学统一考试西医综合试题 |
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