英语查房剧本——妇科宫外孕技术

1、Gynecological Department of Shanghai Shuguang Hospital Affiliated to shanghai University of Traditional Chinese MedicineThe scripts of Ward Round in EnglishEctopic Pregnancy 上海中医药大学附属曙光医院 妇科 英语查房剧本宫外孕 Director: Dr. Zhang Qinhua 张勤华 Attending: Dr. Hu Hui 胡慧 Resident: Dr. Shen Mingjie 沈明洁 Intern: Dr. Yi Yun 易云 Patient: Liujihong 刘继红 Glossary 词汇表ectopic pregnancy: 异位妊娠P.I.D: pelvic inflammatory disease 盆腔炎cervical lifting pain: 宫颈举痛tenderness: 压痛TVS: Transvaginal Ultrasound 经阴道超声Cul-de-sac: 后穹隆Culd

2、ocentesis: 后穹隆穿刺Incoagulable blood: 不凝血Initial impression: 初步诊断Abdominal palpation: 腹部触诊Rebound tenderness: 反跳痛Percussion: 叩诊Shifting dullness: 移动性浊音Vaginal bleeding: 阴道出血contraceptive users: 避孕药使用者IUD: intrauterine device 宫内节育器Intraperitoneal hemorrhage: 内出血ampullary of fallopian tube: 输卵管壶腹部corneal pregnancy: 宫角妊娠Corpus luteum cyst rupture: 黄体破裂Appendicitis: 阑尾炎Salpingitist: 输卵管炎Uterine abortion: 宫内妊娠流产Threatened abortion: 先兆流产Laparoscopy:腹腔镜Laparotomy:剖腹手术MTX: 氨甲喋呤Mifepristione：米非司酮 ASenior r

3、esidents morning report 情景 A：交班Good morning good morning.Director: Is everybody hereOthers: yes.Director: OK Dr. hu lets begin.Attending: Yes The morning meeting now begins. Lets have the report by the physician on callfirst. Dr Shen PleaseResident: Last night there is no special thing happened except a new emergent patient. The patientnamed “Li Fang” bed 6 31-year-old Hospital No. 10707890. She was admitted on 4 am becauseof “severe low abdominal pain for 6 hours”. Our tentative diagnosis is: e

4、ctopic pregnancy. Nowthe condition of the patient is stable. Thats all.主治医师：请注意了 交班开始。先请值班医师交班报告。住院医师：昨晚没有特殊情况，除了一个急诊病人，病人姓名“李芳”6 床，31 岁，住院号：10707890.今晨 4 点，患者因“下腹剧痛 6 小时”入院。初步诊断为异位妊娠，目前病人症情平稳，交班完毕。 BCase Presentation 情景 B: 病史汇报Attending: OK the first case of todays Professors round is the new patient. Dr. shen could youmake a case report主治医师：好的，今天主任查房就从新病人开始。沈医生，你能汇报一下病史吗？Resisdent: Yes. The key points of this case are : first the patient is a 31-year-old marriedwoman having the history of P.I.

5、D one year ago. SecondlyShe began to complain of acute lowabdominal pain especially in the left lower quadrant and became pale about 6 hours beforeadmission with nausea and vomiting. Her last menstrual period occurred 45 days beforeadmission. Thirdly the vaginal examination shows :normal size uterus cervical lifting pain andsevere tenderness on the left side of the pelvis .住院医师：是。本病例的特点是：1.该病人为 31 岁，已婚女性，一年前曾有盆腔炎病史。2.患者因急性下腹痛，左侧痛甚，面色苍白伴恶心呕吐 6 小时入院。末次月经为入院前 45天。3.阴道检查提示子宫正常大小，宫颈举痛，左侧附件明显压痛。Direct

6、or: what about the laboratory examination and the ultrasound of pelvis主任医师：实验室检查和盆腔 B 超检查呢？Resisdent: Yes her laboratory examines were all within normal limits except that her urinepregnancy test is positive. TVS shows :there are an empty uterus free fluid in the cul-de-sac and alump of 3cm in diameter on the left side.住院医师：除尿妊娠试验阳性外，其它实验室检查均正常。阴超提示，宫内未见孕囊，后穹隆积液，左侧附件发现一 3cm 包块。Director: Did you make the culdocentesis to make sure the character of the fluid 主任医师：你有没有做后穹窿穿刺以明确后穹窿积液的性质？Resisdent: Y

7、es I did. the culdocentesis is positive I drew the incoagulable blood from the pelvis.So our initial impression of the case would be ectopic pregnancy. And we have engaged anoperation this noon.住院医师：是的，后穹窿穿刺阳性，我抽出来自盆腔的不凝血。所以我们对该病例的初步诊断是异位妊娠，并已预约今日中午手术。Director: Okay Dr.shen have made a perfect case report just now. nextlets go to the ward andlook at the patient.主任医师：感谢沈医师做了精彩的病例汇报，然后我们去病房看看患者。 CProfessors Ground 情景 C：主任查房场景：病房Director: Hello LIFANG I am Dr. Zhang. Whats your feeling now Do you h

8、ave pain vaginalbleedingor sick and so on主任医师：你好，李芳，我是张医师，你现在觉得怎么样，有没有肚子疼或者出血、恶心？Patient: Hi doctor. I just feel pain in my belly and feel sick.病人：你好，医生。我就是觉得肚子痛而且恶心。Director: ok lers make an examination Dr Yi please do the abdominal palpation.I 主任医师：我们做一下体格检查，易医生，你能做一下腹部触诊。Intern: Yes bent you knees please. Do you feel painYes Here Yes a little ThereYes. Severeor notSevere .实习医师：蜷一下腿。这里痛吗（痛的） ，这里呢？（一点点） ，那里（痛） ，痛的厉害吗？（厉害的）Intern:Face to the director: the abdomen is soft the tender point is in t

9、he left side.实习医师： （面对主任） ：腹软，左侧压痛。Director: Dr Yi you missed some important steps in the examination Follow Me. Firstly wetouch the general abdomen gently to feel it is soft or rigidity the goal of palpation is to findWhere is the tender point Is there muscle guarding Is there rebound painFor this patiient admonen is soft and the maximal tender point is in the left side no musleguarding and then we should make the percussion of the abdomen make it when flatand percussthe left. Turn right please ok thats all . the shifting dullness ispositive. Do you get it主任医师：易医生，你遗漏了体检中的一些重要步骤，看我做。首先，我们轻触诊全腹，感觉腹部是柔软还是僵硬，触诊的目的是寻找哪里是压痛点？有没有肌卫？有没有反跳痛？这个病人，腹部视柔软的，最明显的压痛点在盆腔，没有肌卫。我们还需要做叩诊，请往左侧翻身。做完了。移动性浊音是阳性的。你明白了吗？Intern: Yes I do thank you director.实习医师：是的，谢谢主任。Director: OKthats all. Your condition is not serious so take it easy and have a rest today youwill have an operation dont worry everything will be okay.主任医师：好的，你的情况不是很严重，不要紧张，好 好休息。今天你要动个手术，不要担心，一切都会好的。Patient: doctor

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