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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