Overview Overview

Admission NoteAdmission Note

入院录写作概述入院录写作概述杨明山杨明山

Classification of Medical WritingClassification of Medical Writing

Medical Literature

Medical Medical RecordRecord

Admission NoteAdmission Note

Classification of Medical WritingClassification of Medical Writing MIAs abstractMIAs abstract IMRAD paperIMRAD paper Systematic Systematic

ReviewReview

General Medical General Medical Record Record (History)(History)

Admission NoteAdmission Note Daily RecordDaily Record Discharge NoteDischarge Note

Admission NoteAdmission Note

Clinical RecordClinical Record

POMRPOMRPProblem-roblem-ooriented riented MMedical edical RRecordecord

Lawrence Weed. MD.Lawrence Weed. MD. 1947: Columbia U1947: Columbia U

niversityniversity

？？ : Yale Universit: Yale University School of Medicy School of Medicineine

1964: “Medical re1964: “Medical records, patient carcords, patient care, and medical ede, and medical education”ucation”

Problems ListProblems List

ProblemProblemNo.No.

Active Active ProblemProblem

Onset Onset DateDate

Inactive ProblemInactive Problem Date Date ResolvedResolved

#1#1 Acute Acute peritonitisperitonitis

14/714/7 17/717/7

#2#2 Cholecys-tectomCholecys-tectomyy

Oct/70Oct/70

#3#3 hypertensionhypertension controlledcontrolled

((Admission NoteAdmission Note))

Medical Writing Medical Writing SeriesSeries

4.204.20 methodmethod

入院录入院录

廿句写作法廿句写作法

Chief ComplaintChief Complaint

Section One

Chief ComplaintChief Complaint

Section One

Only 1 sentence

第第 11 句 – 句 – 主诉主诉 - - 写作分析写作分析

A 25 year-old ladyA 25 year-old lady 个人资料was admitted towas admitted to this hospitalthis hospital 被动，过去onon May 11, 2003May 11, 2003 入院日期because of fever and coughbecause of fever and cough 主诉with chillwith chill 次要forfor three days.three days. 持续时间

第第 11 句 – 介词妙用 – 主诉句 – 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.

HistoriesHistories

Section Two

HistoriesHistoriesSection Two

Current History

第第 22 句 – 句 – 起病起病写作分析写作分析

Four days ago, Four days ago, 时间状语the patient took a trip to the patient took a trip to Guangzhou on business.Guangzhou on business.

起病原因

第第 33 句 – 句 – 演变演变写作分析写作分析

Next morning Next morning 状语she had chill and malaise, she had chill and malaise,

and in the afternoon and in the afternoon 状语began to cough and began to cough and temperature went up to temperature went up to 38 .℃38 .℃

演变

第第 44 句 – 句 – 经治经治写作分析写作分析

Self administration Self administration 经治经过of APC and Dicough of APC and Dicough 药物had no effect.had no effect. 效果

第第 44 句 句 - - 其他表达其他表达

home medication home medication

customary medicationcustomary medication

outpatient medicationsoutpatient medications

No treatmentNo treatment

药物药物

bebe

inineffectiveeffective

toto

病症病症人人

ununresponsiveresponsive 干预干预动物动物症状症状体征体征

withwithoutout improvement, effectivenessimprovement, effectiveness

第第 44 句 – 经治句 – 经治效果效果表达表达

第第 55 句 – 句 – 状态状态写作分析 – 无特殊写作分析 – 无特殊

The patient was The patient was

in good nutritional and in good nutritional and conscious conditionconscious condition (of) (of)

状态

on admissionon admission 入院时

现病史写作关键：现病史写作关键： timetime adverbial adverbial

点：点： Since Since the initial diagnosis, ……. the initial diagnosis, ……. 时刻：……时刻：…… . at approximately . at approximately 55 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 …….

HistoriesHistoriesSection Two

Other Histories

第第 66 句 – 过去病史写作分析句 – 过去病史写作分析

The patient The patient has beenhas been healthy healthy 现病多久完成态a week prior to admission a week prior to admission

and and hadhad no special diseases no special diseases previously previously 过去史

过去式including pneumococcal pneincluding pneumococcal pneumonia and TB and umonia and TB and

Family, Personal, Ob/Gyn (Childbearing) H.Family, Personal, Ob/Gyn (Childbearing) H.

Customary medications were xx.Customary medications were xx. His only medication was xx for xx.His only medication was xx for xx. P P did not smoke and rarely consumed did not smoke and rarely consumed

alcohol.alcohol. PP had a x-pack-year smoking history had a x-pack-year smoking history There was a (no) family history of xx.There was a (no) family history of xx. Parents are alive and well.Parents are alive and well. PP died of x at the age of died of x at the age of

第第 77 句 – 家族史写作分析句 – 家族史写作分析

There was There was 存在句

万能句no family historyno family history (of xx) (of xx)

concerned .concerned .

ExaminationsExaminations

Section Three

第第 88 句 – 句 – 生命体征生命体征写作分析写作分析

Body temperatureBody temperature waswas 38.4 , respiration ℃ 38.4 , respiration ℃rate rate waswas 30/min, pulse rate 30/min, pulse rate was was 104 b/min, 104 b/min, and BP and BP waswas 108/72mmHg. 108/72mmHg.

His vital signs His vital signs areare

body temperature 38.4 ,℃body temperature 38.4 ,℃

respiration rate 30/min, respiration rate 30/min,

pulse rate 104 b/min, pulse rate 104 b/min,

and BP 108/72mmHg.and BP 108/72mmHg.

第第 99 句 – 句 – 望诊望诊写作分析写作分析

SheShe 望诊was foundwas found

to be slightly dyspnea.to be slightly dyspnea. 被动

seenseen

observobserveded

recognizrecognizeded

detectdetecteded

visiblevisible

第第 99 句 – 句 – 望诊望诊写作要求写作要求①① 部位部位 : : Vigorous small intestinal peristalsis Vigorous small intestinal peristalsis

can be seen in the center of the abdomencan be seen in the center of the abdomen. .

②② 时间时间 : Symmetrical distension is seen when : Symmetrical distension is seen when

intra-abdominal content is increased.intra-abdominal content is increased.

③③ 特征特征 : An enlarged uterus was seen as a ce: An enlarged uterus was seen as a ce

ntral rounded suprapubic swelling. ntral rounded suprapubic swelling.

④④ 病 理病 理 : : Paralytic ileus is seen in patients Paralytic ileus is seen in patients

after abdominal surgery.after abdominal surgery.

第第 1010 句 – 句 – 叩诊听诊叩诊听诊写作分析写作分析

The right lower posterior chestThe right lower posterior chest 叩诊showedshowed 主动dullnessdullness 阳性onon percussion percussion 方式withwith moist rales moist rales 听诊atat the end of inspiration the end of inspiration 时间on on auscultation.auscultation. 方式

第第 1010 句 – 触诊表达 句 – 触诊表达 To be palpatedTo be palpated ；； To be feltTo be felt

部位：部位： Small masses (nodules) are felt Small masses (nodules) are felt near the uterus or in the cul-de-sac.near the uterus or in the cul-de-sac.

时间时间 :: No fibroids are felt during the biNo fibroids are felt during the bimanual pelvic or rectal exams.manual pelvic or rectal exams.

特征特征 : : His neurologic exam demonstratHis neurologic exam demonstrated mild generalized hypotoniaed mild generalized hypotonia

第第 1010 句 – 叩诊表达 句 – 叩诊表达 To be heardTo be heard ；； tap, strike, flick, Percusstap, strike, flick, Percuss

①① 部位部位 : : These sounds are heard only over the bronThese sounds are heard only over the bron

chi and trachea. chi and trachea.

②② 时间时间 : : Friction was heard in both inspiration and Friction was heard in both inspiration and

expiration.expiration.

③③ 特征特征 :: The cancerous area was felt as a hard, irreThe cancerous area was felt as a hard, irre

gular nodule.gular nodule.

④④ 病理病理 : : It is heard in bronchiectatic cavities or pne

umothorax.

第第 1010 句 – 听诊表达 句 – 听诊表达 ①① locationlocation ：： A soft, high-pitched, holosystolic blowing murA soft, high-pitched, holosystolic blowing mur

mur is heard in the mitral area. mur is heard in the mitral area.

②② timetime ：： A murmur can be heard during the diastole.A murmur can be heard during the diastole.

③③ featurefeature

His lungs were clear to auscultation.His lungs were clear to auscultation.

④④ otherother

An aortic murmur is heard with the patient sittinAn aortic murmur is heard with the patient sitting forward in full expiration.g forward in full expiration.

第第 1010 句句 四诊句型四诊句型 -- 介词短语介词短语

On physical examination, …On physical examination, …

A tapping apex beat may be apparent A tapping apex beat may be apparent oo

n n inspection. (inspection. ( 最多）最多）

Ill-defined nodule marginsIll-defined nodule margins by by palpation palpation

The nodule was evident The nodule was evident at at palpationpalpation

第第 1111 句 – 辅助检查写作分析句 – 辅助检查写作分析

X-ray filmsX-ray films of the chest over of the chest over 项目showedshowed 主动cloudy patchescloudy patches 特征both lower lungs in the posterior-both lower lungs in the posterior-anterior view and the lateral view.anterior view and the lateral view.

部位方式

Imaging, Ultrasound and OthersImaging, Ultrasound and Others

Doppler studiesDoppler studies revealed revealed normal blood normal blood

flow to bothflow to both ovaries.ovaries.

A friableA friable lesionlesion 15 to 20 mm in diameter 15 to 20 mm in diameter

was identifiedwas identified very low in the rectum. very low in the rectum.

During a digital rectal examination, a During a digital rectal examination, a

mobile, softmobile, soft mass mass was foundwas found low in the low in the

left rectum.left rectum.

⒂⒂ Imaging, Ultrasound and OthersImaging, Ultrasound and Others

PatternPattern ExamExam showed … showed … The liverThe liver was shown to be enlarged… was shown to be enlarged… The heart murmurThe heart murmur was heard … was heard … 检查检查项目项目作主语：主动态作主语：主动态 阳性阳性体征体征作主语：被动态作主语：被动态 人的人的器官器官作主语：被动态作主语：被动态

第第 1212 句 – 实验写作分析句 – 实验写作分析

The white blood cell countThe white blood cell count 项目waswas 主系表10.0 x 109/L (8,000/cu mm).10.0 x 109/L (8,000/cu mm).

第第 1212 句 – 句 – lab lab 表达 表达 - Same- Same Item was Item was normal.normal. Item Item was positivepositive Item Item was negativenegative Item Item was numbernumber

A serologic test for antibody to Helicobacter pylA serologic test for antibody to Helicobacter pylori was positive. ori 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 1313 句 – 采样写作分析句 – 采样写作分析

And the bloodAnd the blood 标本has been sampledhas been sampled 完成forfor

liver function, kidney function, liver function, kidney function, arterial gas analysis as well as PCRarterial gas analysis as well as PCR

项目

第第 1414 句 – 写作分析 – 回报句 – 写作分析 – 回报

Those lab reportsThose lab reports

haven’t haven’t arrived.arrived.

完成时态returned.returned.

come back.come back.

been back.been back.

UniversalUniversal There-be There-be 万能句万能句 Current History: Current History: On the sixth day, On the sixth day, there wasthere was an episode of bradycardi an episode of bradycardi

a and vomitinga and vomiting Previous Hisroty: Previous Hisroty: There wasThere was no history of sexually transmitted disease. no history of sexually transmitted disease. InspectionInspection There wasThere was swelling in one rear “ankle” as well. swelling in one rear “ankle” as well. PalpationPalpation There wasThere was a large hard irregular mass in the abdome a large hard irregular mass in the abdome

n.n. PercusionPercusion There wasThere was a minimal corneal reflex in the left eye. a minimal corneal reflex in the left eye. AusculationAusculation There wereThere were scattered rales and rhonchi all over the lu scattered rales and rhonchi all over the lu

ng fields.ng fields.

ApproachApproach

Section Four

第第 1515 句 – 正文 – 诊断句 – 正文 – 诊断Our Our

impression impression

of the case of the case

would be would be

severe acute severe acute

respiratory respiratory

syndrome. syndrome.

第第 1515 句 – 诊断写作分析句 – 诊断写作分析

Our impression of the case. Our impression of the case.

诊断Our tentative diagnosisOur tentative diagnosis

Our initial diagnosisOur initial diagnosis

would bewould be 虚拟severe acute respiratory severe acute respiratory syndromesyndrome

主要诊断

第第 1616 句 – 治疗写作分析句 – 治疗写作分析

On the day of admission, On the day of admission, 时间the patientthe patient

was givenwas given 过去；停用

第第 1616 句 – 治疗其他表达句 – 治疗其他表达

Xx givenXx given

Xx prescribedXx prescribed

Xx institutedXx instituted

Xx was Xx was

administeredadministered

administered administered

taken orallytaken orally

injectedinjected

infused infused

intravenously, intravenously,

intramuscularly, intramuscularly,

by TPNby TPN

第第 1717 句 – 写作分析句 – 写作分析

Oxygen and CPAPOxygen and CPAP

have beenhave been 完成applied. applied. 应用至今

第第 1818 句 – 当前问题写作分析句 – 当前问题写作分析

HoweverHowever

the patient’s temperaturethe patient’s temperature

is still going onis still going on 当前问题and dyspneaand dyspnea

tends to betends to be 将来表达more severe.more severe.

第第 1919 句 – 写作分析句 – 写作分析

The patientThe patient

will be givenwill be given 计划tracheostomytracheostomy 治疗in case of emergency.in case of emergency. 将来时间

第第 2020 句 – 写作分析句 – 写作分析And meanwhile the patientAnd meanwhile the patient

will be givenwill be given 将来prednisoloneprednisolone 双刃剑whenwhen the patient develops the patient develops 状语从句the early sign of respiratory the early sign of respiratory failurefailure

or or ifif infiltrate patch is over one infiltrate patch is over one third of the both lung fields.third of the both lung fields.

条件从句

诊疗诊疗计划计划

一般一般

将来时将来时

will be giwill be gi

venven

条件状语条件状语短语短语 ,, 从从

句句

in case of in case of emergencyemergency

时间状语时间状语短语短语 ,, 从从

句句

when the patiewhen the patient develops sth.nt develops sth.

入院入院 : : 一般过去一般过去 - was- was given given至今至今 : : 现在完成现在完成 - - has beenhas been give givenn目前目前 : : 现在进行现在进行 -- is beingis being given given将来将来 : : 一般将来一般将来 -- will bewill be given given

SummarySummary

C.C. 4-section4-section

1.1. Personal details Personal details （个人资料）（个人资料）2.2. Admission dateAdmission date （入院日期（入院日期3.3. Major complaintMajor complaint （主诉）（主诉）4.4. Present historyPresent history （现病史）（现病史）5.5. previous & other historiesprevious & other histories （过去病史等）（过去病史等）6.6. Physical examination donePhysical examination done （体检）（体检）7.7. Laboratory doneLaboratory done （实验室检查）（实验室检查）8.8. ImpressionImpression （印象）（印象）9.9. Problems Problems （问题列单） （问题列单） 10.10. Initial plan for treatmentInitial plan for treatment （初步处理）（初步处理）

病史病史

检查检查

处理处理

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,. Four days ago,. 2.2. A 25 year-old lady was admitted toA 25 year-old lady was admitted to3.3. The next day she complained of The next day she complained of 4.4. Self administration ofSelf administration of5.5. The patient was in goodThe patient was in good6.6. The patient has beenThe patient has been7.7. Physical examination on admission:Physical examination on admission:8.8. Body temperature (was)Body temperature (was)9.9. And she was foundAnd she was found10.10. The right lower posterior chest The right lower posterior chest

showedshowed

11.11. X-ray films of the chest showed X-ray films of the chest showed 12.12. The white blood cell count The white blood cell count 13.13. And the blood has been sampledAnd the blood has been sampled14.14. Those lab reports haven’t arrived. Those lab reports haven’t arrived. 15.15. Our impression of the case would be Our impression of the case would be 16.16. On the day of admission,On the day of admission,17.17. Oxygen and CPAPOxygen and CPAP18.18. However the patient’s temperature is However the patient’s temperature is 19.19. The patient will be givenThe patient will be given20.20. And meanwhile the patient will be givenAnd meanwhile the patient will be given

The Marriage of Figaro - Overture The Marriage of Figaro - Overture (1786)(1786)

The case presentation based The case presentation based

on the admission note is the on the admission note is the

overture of the Medical overture of the Medical

bilingual educationbilingual education

I wish you would be a new I wish you would be a new generation of clinicians with generation of clinicians with

bilingual capability.bilingual capability.

THANK YOUTHANK YOU