《醫(yī)學(xué)英語(yǔ)實(shí)用情景教程》（徐青） Unit 7 Otorhinolaryngology,Head and Neck Surgery 耳鼻咽喉頭頸外科

醫(yī)學(xué)英語(yǔ)實(shí)用情景教程Unit7Otorhinolaryngology,HeadandNeckSurgery

耳鼻咽喉頭頸外科知識(shí)目標(biāo)掌握耳鼻咽喉頭頸外科常見(jiàn)疾病的英文術(shù)語(yǔ)。掌握詢(xún)問(wèn)、描述耳鼻咽喉頭頸外科常見(jiàn)疾病的相關(guān)英文表達(dá)。掌握耳鼻咽喉頭頸外科英文病歷的寫(xiě)法。技能目標(biāo)能用英語(yǔ)與耳鼻咽喉頭頸外科患者溝通。能讀懂耳鼻咽喉頭頸外科相關(guān)的英文病歷。思政目標(biāo)強(qiáng)化勇挑重?fù)?dān)，為祖國(guó)醫(yī)療衛(wèi)生事業(yè)發(fā)展貢獻(xiàn)力量的意識(shí)。項(xiàng)目目標(biāo)1．學(xué)習(xí)“知識(shí)儲(chǔ)備”中的內(nèi)容，掌握本單元的重點(diǎn)醫(yī)學(xué)術(shù)語(yǔ)和常用表達(dá)。2．跟讀“醫(yī)患交流”下的英文對(duì)話，然后角色扮演各對(duì)話場(chǎng)景。3．仔細(xì)閱讀“病歷閱讀”下耳鼻咽喉頭頸外科相關(guān)的英文病歷，總結(jié)其中重點(diǎn)句型及詞匯。4．完成本單元的“任務(wù)檢測(cè)”。5．根據(jù)以上任務(wù)的完成情況，給自己評(píng)分。任務(wù)描述目錄123知識(shí)儲(chǔ)備醫(yī)患交流病歷閱讀章節(jié)導(dǎo)航01知識(shí)儲(chǔ)備CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryKeyWordsandExpressionsModelSentencesCommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryotitismedia /???ta?t?s?mi?d?? 中耳炎耳部疾病subjectivetinnitus/s?b?d?ekt?v?t?n?t?s 主覺(jué)性耳鳴chroniclymphadenitis/?kr?n?kl?m?f?d??na?t?s 慢性淋巴結(jié)炎

CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryatrophicrhinitis /?'tr?f?kra??na?t?s 萎縮性鼻炎allergicrhinitis /??l??d??kra??na?t?s 變應(yīng)性鼻炎nasalpolyp /?ne?zl?p?l?p 鼻息肉deflectionofnasalseptum /d??flek?n?v?ne?zl?sept?m 鼻中隔偏曲epistaxis /?ep??st?ks?s 鼻衄，鼻出血nasosinusitis /n?s??za??n?sa?t?s 鼻竇炎chronicsinusitis /?kr?n?k?sa?n??sa?t?s 慢性鼻竇炎cystofnasalsinus /s?st?v?ne?zl?sa?n?s 鼻竇囊腫鼻部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgerynasalvestibularcyst /?ne?zlve?st?bj?l?s?st 鼻前庭囊腫nasopharyngealcarcinoma /?ne?z??f??r?nd???l?kɑ?s??n??m? 鼻咽癌nosebonefracture /n??zb??n?fr?kt??(r)/ 鼻骨骨折pharyngitis /?f?r?n?d?a?t?s 咽炎asthmaticbronchitis /?s?m?t?kbr???ka?t?s 哮喘性支氣管炎hyperplasticpharyngitis /?ha?p??plɑ?t?k?f?r?n?d?a?t?s/ 肥厚性咽炎，增生性咽炎pharyngitissicca /?f?r?n?d?a?t?s?s?k? 干燥性咽炎acutetonsillitis /??kju?t?t?ns??la?t?s 急性扁桃體炎咽部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryadenoidhypertrophy /??d??n??dha??p??tr?f? 腺樣體肥大pharyngealparaesthesia /f??r?nd???l?p?r?s?θi?z?? 咽異感癥obstructivesleepapneahypopneasyndrome /?b?str?kt?vsli?p??pn??ha?'p?pn???s?ndr??m/ 阻塞性睡眠呼吸暫停低通氣綜合征vocalnodule /?v??kl?n?dju?l 聲帶小結(jié)，聲帶結(jié)節(jié)polypofvocalcord /?p?l?p?v?v??klk??d 聲帶息肉咽部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgerychroniclaryngitis /?kr?n?k?l?r?n?d?a?t?s 慢性喉炎laryngealarthritis /l??r?nd???lɑ??θra?t?s 喉關(guān)節(jié)炎laryngospasm /l?'r??ɡ?sp?z?m 喉痙攣functionalaphonia /?f??k??nl??f??n?? 功能性失聲benigntumoroflarynx /b??na?n?tju?m?(r)?v?l?r??ks 喉良性腫瘤laryngealedema /l??r?nd???l??di?m? 喉頭水腫喉部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgerythyroidadenoma /?θa?r??d??d??n??m?/甲狀腺腺瘤頸部疾病jugularphlebitis/?d??ɡj?l?(r)fl??ba?t?s/頸靜脈炎torticollis/?t??t??k?l?s/斜頸KeyWordsandExpressionspersistent /p??s?st?n/ adj. 持續(xù)的；反復(fù)出現(xiàn)的appetite /??p?ta?t/ n. 食欲；胃口swallow /?sw?l??/ v. 吞下；咽下thermometer /θ??m?m?t?(r)/ n. 體溫計(jì)；溫度計(jì)KeyWordsandExpressionsswab /sw?b n.

（醫(yī)用的）拭子，藥簽inflame /?n?fle?m v.

（使）發(fā)炎infectious /?n?fek??s adj.

傳染性的，感染的insomecases 某種情況下antibiotic /??nt?ba???t?k n.

抗生素apartfrom 除了……外；此外；加之hearingloss 聽(tīng)力減退，聽(tīng)力損耗nasalmucus /?ne?zl?mju?k?s n. 鼻涕；鼻黏液MRI abbr.magneticresonanceimaging磁共振成像 /m?ɡ?net?k?rez?n?ns??m?d???/KeyWordsandExpressionshorrible /?h?r?bl/ adj.

令人震驚的；恐怖的medication /?med??ke??n/ n. 藥；藥物surgicaloperation /?s??d??kl??p??re??n/ 外科手術(shù)inaccordancewith 與……一致，依照specification /?spes?f??ke??n/ n.

明細(xì)單；說(shuō)明書(shū)bruise /bru?z/ v.

挫傷；撞傷；擦傷relief /r??li?f/ v. （焦慮、痛苦等的）減輕，消除，緩和slightfever 微熱，低燒thick /θ?k/ adj.

濃的；黏稠的speculum /?spekj?l?m/ n.

窺器；擴(kuò)張器flashlight /?fl??la?t/ n.

手電筒，手電occupation /??kj??pe??n/ n.

工作；職業(yè)ModelSentences1.Ihavehadapersistentcoughandsorethroatthesedays.我最近這幾天一直咳嗽，而且喉嚨痛。2.Yourthroatisseriouslyinflamedandthesurfaceofthemouthandthroatareentirelyred.你的喉嚨已經(jīng)嚴(yán)重發(fā)炎了，口腔內(nèi)壁及咽喉表面均因感染而生紅。4.Pleasedonotdrink;eatneitherspicynorsaltyfood.不要飲酒，不要吃辛辣的、咸的食物。3.Ihaveneverbeenallergictoantibiotics.我對(duì)任何抗生素都不過(guò)敏。ModelSentences5.Doyoubreathewellwhensleeping?你睡覺(jué)的時(shí)候呼吸是否通暢？6.Surgicaloperationisthemosteffectivewaytocurethedisease.手術(shù)是治愈這種病最有效的方法。8.AnX-rayscanofyournoseshouldbedonetoseeifthereisafracture.你需要去做一個(gè)X光掃描來(lái)看看鼻骨是不是骨折了。7.Takethemedicineinaccordancewiththespecification.按照說(shuō)明書(shū)服用給你開(kāi)的藥。ModelSentences9.Doyousleepwell?Andwhatothersymptomsdoyouhave?你睡得好嗎？還有沒(méi)有其他癥狀？10.Whatdoesthenasalmucuslooklike?Andhowaboutitscolorandsmell?鼻涕是什么樣子的？顏色和氣味如何？12.It’sdifficultformetofallasleep,soIdon’thaveenoughhigh-qualitysleep.我很難入睡，所以沒(méi)有充足的高質(zhì)量睡眠。11.I’llopenyournasalcavitywithaspeculumandthenuseaflashlighttolookinsideyournose.我要用擴(kuò)張器打開(kāi)你的鼻腔，然后用手電筒看看你的鼻子內(nèi)部。ModelSentences13.Cervicalspondylosisisprobablycausedbythepoorposturewithprolongedsittingandlotsofstress.頸椎病很可能是不良姿勢(shì)的久坐和巨大壓力引起的。14.Doingdailyneckexerciseswillhelpyourecoverfromcervicalspondylosis.每天做頸椎運(yùn)動(dòng)有助于你的恢復(fù)。課堂小結(jié)這小結(jié)我們學(xué)習(xí)了耳鼻咽喉頭頸外科醫(yī)學(xué)中的常見(jiàn)病、關(guān)鍵詞和表達(dá)式和模型句子。希望大家能加深對(duì)英語(yǔ)詞匯的理解并靈活應(yīng)用。02醫(yī)患交流Conversation1AcuteTonsillitis急性扁桃體炎Conversation2NasopharynxCarcinoma鼻咽癌Conversation3NoseBoneFracture鼻骨骨折Conversation4ChronicSinusitis慢性鼻竇炎Conversation5CervicalSpondylosis頸椎病Conversation1AcuteTonsillitis急性扁桃體炎P:Goodmorning,doctor.D:Goodmorning,what’syourtrouble?P:Ihavehadapersistentcoughandsorethroatthesedays.D:Hmm,youlookabityellow.Haveyoubeeneatingnormally?

P:No.I’velostmyappetiterecently.It’sdifficultformetoswallow,andIcanonlyeatsomefluids.SometimesIwanttovomit.D:Isee.Howlonghaveyoubeenlikethis?

P:Foralmostthreedays.患者：早上好，醫(yī)生。醫(yī)生：早上好，你怎么了？患者：我最近這幾天一直咳嗽，而且喉嚨痛。醫(yī)生：嗯，你臉色看起來(lái)有點(diǎn)黃。這幾天飲食正常嗎？患者：不正常，我最近胃口不好。因?yàn)橥萄世щy，我只能吃一些流質(zhì)食物，有時(shí)候還想吐。醫(yī)生：明白了。那你從什么時(shí)候開(kāi)始有這個(gè)癥狀的？患者：差不多三天了。Conversation1AcuteTonsillitis急性扁桃體炎D:Putthisthermometerunderyourtongue,please.(afewminuteslater)You’vegotaslightfever.Canyouopenyourmouthwideandletmecheckit?Doyoufeelanypainherenow?P:Yes,ithurtswhenyouhititwiththeswab.What’swrongwithme,doctor?Isitserious?D:Yourthroatisseriouslyinflamedandthesurfaceofthemouthandthroatareentirelyred.Itseemsthatyou’vegotacutetonsillitis.P:It’sinfectious,isn’tit?醫(yī)生：請(qǐng)把這根體溫計(jì)含在舌下。（幾分鐘后）你有點(diǎn)發(fā)燒。你能張大嘴巴，讓我檢查一下嗎？現(xiàn)在這里痛嗎？患者：嗯，你用棉簽按壓時(shí)痛。醫(yī)生，我這是怎么了？嚴(yán)不嚴(yán)重呀？醫(yī)生：你的喉嚨已經(jīng)嚴(yán)重發(fā)炎了，口腔內(nèi)壁及咽喉表面均因感染而生紅。看來(lái)你這是得了急性扁桃體炎。患者：這種病會(huì)傳染，是嗎？Conversation1AcuteTonsillitis急性扁桃體炎D:Well,yes,insomecases.Butdon’tfeelsoupset.Iwillprescribeyousomemedicine.Andyouwillsoonrecoverfromit.Areyouallergictoanykindofantibiotics?P:Ihaveneverbeenallergictoantibiotics.WhatelsedoIneedtopayattentionto?D:Pleasedonotdrink;eatneitherspicynorsaltyfood.P:Thankyouverymuch,doctor.D:Mypleasure.Seeyou!醫(yī)生：嗯，是的，某種情況下會(huì)。但是不用這么難過(guò)，我給你開(kāi)些藥，你很快就會(huì)恢復(fù)。你對(duì)抗生素過(guò)敏嗎？患者：我對(duì)任何抗生素都不過(guò)敏。還有什么需要我注意的嗎？醫(yī)生：不要飲酒，不要吃辛辣的、咸的食物?；颊撸悍浅８兄x，醫(yī)生。醫(yī)生：非常榮幸，一會(huì)兒見(jiàn)。Conversation2NasopharynxCarcinoma鼻咽癌P:Ihaveaterriblerunningnose.Apartfromthat,Ihaveaheadacheandahearingloss.D:Isthereanybloodinyournasalmucus?P:Yes,sometimes.D:Doyoubreathewellwhensleeping?P:No,notsowell.Icanhardlybreathewell.Andatmidnight,Icoughedviolently.D:Howlonghaveyoubeenlikethis?P:Morethanoneyear.D:YoushoulddoabloodtestandanMRIscanofthenose.患者：醫(yī)生，我鼻涕流得厲害。此外，我還頭痛，聽(tīng)力也下降了。醫(yī)生：鼻涕里帶血嗎？患者：是的，有時(shí)候帶血。醫(yī)生：你睡覺(jué)的時(shí)候呼吸是否通暢？患者：不是很通暢，幾乎要喘不過(guò)氣來(lái)了，而且半夜咳嗽得很厲害。醫(yī)生：這樣的癥狀持續(xù)多長(zhǎng)時(shí)間了？患者：已經(jīng)超過(guò)一年了。醫(yī)生：你應(yīng)該先做個(gè)血液檢測(cè)和鼻部核磁共振掃描。Conversation2NasopharynxCarcinoma鼻咽癌P:OK.Iwillbebacksoonwiththeresults.Seeyouthen.(aftertheresultscomeout)D:Accordingtotheresults,youaresufferingfromnasopharynxcancer.P:It’shorrible!WhatshouldIdo?D:Don’tworry.Iwillprescribeyousomemedicationtohelpyoucontrolthecancer.Andifpossible,youcanhaveasurgicaloperationwhichisthemosteffectivewaytocurethedisease.患者：好的。我很快會(huì)拿著檢查結(jié)果再過(guò)來(lái)。到時(shí)候見(jiàn)。（檢查結(jié)果出來(lái)后）醫(yī)生：根據(jù)檢查結(jié)果，你得的是鼻咽癌?；颊撸哼@太可怕了！我該怎么辦？醫(yī)生：不用擔(dān)心，我會(huì)給你開(kāi)些藥來(lái)幫你控制病情。如果病情控制住了，就可以進(jìn)行手術(shù)。手術(shù)是治愈這種病最有效的方法。Conversation2NasopharynxCarcinoma鼻咽癌P:Whatarelief!Thankssomuch.D:Areyouallergictoanykindofmedicine?P:No,neverhadbefore.D:OK.Takethemedicineinaccordancewiththespecification.P:Thankssomuch.D:Mypleasure.Hopeyourecoversoon.患者：這下我放心了！太感謝了。醫(yī)生：你對(duì)什么藥物過(guò)敏嗎？患者：沒(méi)有，之前沒(méi)有過(guò)敏過(guò)。醫(yī)生：好了。按照說(shuō)明書(shū)服用給你開(kāi)的藥。患者：非常感謝。醫(yī)生：不客氣，希望你盡快康復(fù)。Conversation3NoseBoneFracture鼻骨骨折P:Goodmorning,doctor.D:What’sthetrouble?P:Ifellandstruckmynoseontheflooryesterday.Unfortunately,mynosewasbadlybruised.Ithurtsmesomuch.D:Letmelookyouovercarefully.P:Justhere!Ouch!Mynose!D:AnX-rayscanofyournoseshouldbedonetoseeifthereisafracture.(aftertheX-ray)Yes,itisafracture.P:Canyouprescribemesomepainkillerstorelievethepain?D:Areyouallergictoanytypeofmedication?患者：早上好，醫(yī)生。醫(yī)生：你怎么了？患者：昨天我摔倒了，鼻子磕在了地板上。不幸的是，我的鼻子嚴(yán)重挫傷。太疼了。醫(yī)生：讓我仔細(xì)檢查一下?；颊撸壕褪沁@兒！哎呦，我的鼻子！醫(yī)生：你需要去做一個(gè)X光掃描來(lái)看看鼻骨是不是骨折了。（做完X光后）是的，是骨折。患者：你可以給我開(kāi)點(diǎn)止疼藥緩解一下疼痛嗎？醫(yī)生：你對(duì)什么藥品過(guò)敏嗎？Conversation3NoseBoneFracture鼻骨骨折P:Idon’tknowexactly.D:Irecommendthisbrandforaquickrelief.P:Willthisreallyhelp?D:Yes.Hereyouare.Theinstructionsonittellyouhowtotakeit.Makesureyoureadthemcarefully.P:Thankyouforremindingme.D:Hopeyourecoversoon.P:Thankyou.D:Youarewelcome.患者：我不太清楚。醫(yī)生：我推薦你使用這一品牌的快速止痛藥?；颊撸哼@藥真的有效果嗎？醫(yī)生：有效果。給你。上面的說(shuō)明會(huì)告訴你怎么服用，一定得看仔細(xì)了。患者：謝謝你的提醒。醫(yī)生：希望你早日康復(fù)?；颊撸褐x謝。醫(yī)生：不客氣。Conversation4ChronicSinusitis慢性鼻竇炎P:Goodmorning,doctor.D:What’sthetrouble,youngman?P:Igotabadcoldlastmonth.Sincethen,Ihavehadarunningnoseandabadheadache.Ifelttootiredtoworkinthedaytime.D:Doyousleepwell?Andwhatothersymptomsdoyouhave?P:Mysleepqualityispoor.AndIhaveaslightfeversometimes.D:Whatdoesthenasalmucuslooklike?Andhowaboutitscolorandsmell?P:Itisthick,whilethecolorandsmellareabnormal.患者：早上好，醫(yī)生。醫(yī)生：你怎么了，年輕人？患者：上個(gè)月我得了重感冒。從那以后，我就一直流鼻涕，而且頭痛得厲害，白天感覺(jué)太疲憊以至于無(wú)法專(zhuān)心工作。醫(yī)生：你睡得好嗎？還有沒(méi)有其他癥狀？患者：我睡眠質(zhì)量不好，而且偶爾發(fā)低燒。醫(yī)生：鼻涕是什么樣子的？顏色和氣味如何？

患者：比較黏稠，顏色和氣味也不正常。Conversation4ChronicSinusitis慢性鼻竇炎D:Pleasesitdownandjustrelax.I’llopenyournasalcavitywithaspeculumandthenuseaflashlighttolookinsideyournose.P:OK.(afterfiveminutes)D:Oh,youmaysufferfromchronicsinusitis.HaveyoueverhadaCTscanofyournoseinanyhospital?P:No.D:Hmm,youhavetodoanoseCTscantoconfirmthediagnosisofchronicsinusitis.醫(yī)生：請(qǐng)坐下，放松。我要用擴(kuò)張器打開(kāi)你的鼻腔，然后用手電筒看看你的鼻子內(nèi)部。患者：好的。（5分鐘過(guò)后）醫(yī)生：哦，你可能患有慢性鼻竇炎。你之前在醫(yī)院做過(guò)鼻部CT檢查嗎？患者：沒(méi)做過(guò)。醫(yī)生：嗯，你必須做一個(gè)鼻部CT掃描來(lái)確認(rèn)慢性鼻竇炎的診斷。Conversation4ChronicSinusitis慢性鼻竇炎P:Noproblem.D:ComebackwithyourexaminationresultsandIwillprescribeyousomemedication.P:Thanksalot.Seeyouthen.D:Seeyou.患者：沒(méi)問(wèn)題。醫(yī)生：帶上你的檢查結(jié)果回來(lái)，到時(shí)候我會(huì)給你配些藥?；颊撸悍浅８兄x您，一會(huì)兒見(jiàn)。醫(yī)生：一會(huì)兒見(jiàn)。Conversation5CervicalSpondylosis頸椎病P:Hello,doctor.I’vegotapaininmyneckrecently.D:Doyouhaveastiffneck?P:Yes,alittle.D:Whatisyouroccupation?P:I’maprogrammerandIhavelongworkinghoursfromMondaytoSaturday.D:Doyousleepwell?P:It’sdifficultformetofallasleep,soIdon’thaveenoughhigh-qualitysleep.D:Pleaselieonyourback,relaxyourmusclesandletmehaveacheck.DoesithurtwhenIpressthisplace?P:Yes,ithurtssomuch.Pleasedonotpressthisplacethathard.患者：你好，醫(yī)生。這些天我脖子有點(diǎn)痛。醫(yī)生：你覺(jué)得脖子僵硬嗎？患者：是的，有點(diǎn)。醫(yī)生：你是做什么工作的？患者：我是個(gè)程序員，周一到周六都需要工作，工作時(shí)間特別長(zhǎng)。醫(yī)生：你睡得好嗎？患者：我很難入睡，所以沒(méi)有充足的高質(zhì)量睡眠。醫(yī)生：請(qǐng)?zhí)上?，放松肌肉，讓我檢查一下。我按壓這里的時(shí)候疼嗎？患者：是的，很疼。請(qǐng)不要那么用力按這里。Conversation5CervicalSpondylosis頸椎病D:Clearly,youaresufferingfromcervicalspondylosis.P:Oh,what’sthecauseofthiskindofdisease?D:Therearemanyfactorsthatcanleadtothisdisease.Butforyou,theyareprobablythepoorposturewithprolongedsittingandlotsofstress.P:Thencanyouprescribemesomemedicationstoeasemyneckpain?D:Ofcourse.What’smore,doingdailyneckexerciseswillhelpyourecoverfromcervicalspondylosis.P:OK.Thankyouverymuch,doctor.醫(yī)生：很明顯，你得了頸椎病?；颊撸号?，什么會(huì)引起這種??？醫(yī)生：有很多因素可以引起這種病。但對(duì)你來(lái)說(shuō)，可能是不良姿勢(shì)的久坐和巨大壓力引起的?；颊撸耗悄隳軒臀议_(kāi)些藥來(lái)緩解脖子的痛嗎？醫(yī)生：當(dāng)然可以。此外，每天做頸椎運(yùn)動(dòng)有助于你的恢復(fù)。

患者：好的，謝謝醫(yī)生。課堂小結(jié)這小結(jié)我們學(xué)習(xí)了如何用英語(yǔ)進(jìn)行醫(yī)患交流。希望大家課下多加復(fù)習(xí)，加深對(duì)英語(yǔ)的靈活應(yīng)用。03病歷閱讀OutpatientMedicalRecords—AcutePurulentTonsillitisAdmissionMedicalRecords(HistoryCollection)—DeviationofNasalSeptumSurgicalRecords—ChronicOtitisMediaPhysicalExamination—DeviationofNasalSeptumChiefComplaint:Odynphagiaaccompaniedwithfeverfor3days.HistoryofPresentIllness:Sincetheonset,thepatienthadodynphagiaaccompaniedwithfever,headacheandasthenia,withouttrismus,shiver,convulsionanddyspnea.PastMedicalHistory:Thepatientwashealthypreviously,withouthistoryofdrugallergy,medicalhistoryofhypertensionanddiabetes,andmedicalhistoryofheartandpulmonarydiseases.PhysicalExamination:Temperature:39℃ Pulse:80bpmRespiratoryRate:18times/min BloodPressure:110/76mmHgHyperemiaandswellingofpharynxoraliswerefound,withgradeⅡbilateralantiadoncus.OutpatientMedicalRecords—AcutePurulentTonsillitisAuxiliaryExamination:BloodRoutineExamination:WBC7.2×109/L;PLT48×109/L;lymphocytepercentage(LYMPH)16.9%BloodType:TypeAPrimaryDiagnosis:AcutetonsillitisTreatment:1.Treatmentwithantibiotics. 2.Reinforceimmunity.Doctor’sSignature:Zhang××OutpatientMedicalRecords—AcutePurulentTonsillitisOutpatientMedicalRecords—AcutePurulentTonsillitis門(mén)診病歷—急性化膿性扁桃腺炎主訴：吞咽痛伴發(fā)熱3天。現(xiàn)病史：患者發(fā)病以來(lái)吞咽疼痛，伴發(fā)熱、頭痛、全身乏力。無(wú)張口困難，無(wú)寒戰(zhàn)、抽搐，無(wú)呼吸困難。既往史：平素體健，無(wú)藥物過(guò)敏史，無(wú)高血壓、糖尿病病史，無(wú)心、肺疾病史。體格檢查：體溫：39℃ 脈搏：80次/分呼吸：18次/分 血壓：110/76mmHg口咽部有充血、腫脹，雙扁桃體Ⅱ度腫大。OutpatientMedicalRecords—AcutePurulentTonsillitis門(mén)診病歷—急性化膿性扁桃腺炎輔助檢查：血常規(guī)：白細(xì)胞（WBC）7.2×109/L，血小板（PLT）48×109/L，淋巴細(xì)胞百分比（LYMPH）16.9%。血型：A型初步診斷：急性扁桃體炎處置：1．抗生素藥物治療。

2．增強(qiáng)免疫。醫(yī)師簽名：張××Name:Ren×× Gender:FemaleAge:29yearsold Race:HanOccupation:Worker MaritalStatus:UnmarriedNationality:China NativePlace:××PresentAddress:×××× RepresentorofMedicalHistory:PatientDateofAdmission:17thSept.,2019 DateofRecord:17:00,17thSept.,2019ChiefComplaint:Nasalobstructionandnasalpurulentsecretionfor9years.HistoryofPresentIllness:Thepatienthadnasalpurulentsecretionandnasalobstructionwithoutevidentreason9yearsago,withoutfever,dizzinessandheadache,etc.Thepatientwasdiagnosedwith“deviationofnasalseptum”byalocalhospitalandoperationwassuggested.Thepatientselecteddrugtreatment(withunknowndetails)duetolackofmoney.AdmissionMedicalRecords(HistoryCollection)—DeviationofNasalSeptumAtpresent,thepatientvisitedourhospitalforoperation,andwasadmittedintoourdepartmentfromclinicas“deviationofnasalseptum”.Sincetheonset,thepatient’sspiritandphysicalpowerwereordinary,withnormalappetite,urinationandstool.PastMedicalHistory:Thepatientwashealthypreviously,withouthistoryofdrugallergy,medicalhistoryofhypertensionanddiabetes,andmedicalhistoryofheartandpulmonarydiseases.PersonalHistory:Thepatientwasbornandgrewupinnativeplace,withordinarylivingcondition.Thepatientdeniedcontacthistoryofdrugs,historyofsmokinganddrinking.MenstrualHistory:Thepatient’smenarchewas14yearsold,lastingfor4-5days.Thecyclewas30days.Thelastmenstrualperiodwas1stSept.,2019.MarriageandChild-bearingHistory:Unmarriedwithoutchild.FamilyHistory:Thepatient’sparentswereingoodhealth.Doctor’sSignature:Wang××AdmissionMedicalRecords(HistoryCollection)—DeviationofNasalSeptumAdmissionMedicalRecords(HistoryCollection)—DeviationofNasalSeptum入院病歷（病史采集）—鼻中隔偏曲姓名：任×× 性別：女年齡：29歲 民族：漢職業(yè)：工人 婚姻狀況：未婚國(guó)籍：中國(guó) 籍貫：××現(xiàn)住址：×××× 病史陳述者：本人入院日期：2019-09-17 病歷記錄時(shí)間：2019-09-17，17:00主訴：鼻塞，鼻內(nèi)有膿性分泌物，持續(xù)9年。現(xiàn)病史：患者9年前無(wú)明顯誘因鼻內(nèi)有膿性分泌物，鼻塞。無(wú)發(fā)熱、頭暈和頭痛等不適。當(dāng)?shù)蒯t(yī)院診斷為“鼻中隔偏曲”，建議手術(shù)，因經(jīng)濟(jì)原因選擇藥物治療（具體不詳）?，F(xiàn)患者欲手術(shù)，來(lái)我院就診，門(mén)診以“鼻中隔偏曲”收入我科?；疾∫詠?lái)，患者精神、體力一般，飲食正常，二便正常。AdmissionMedicalRecords(HistoryCollection)—DeviationofNasalSeptum入院病歷（病史采集）—鼻中隔偏曲既往史：平素體健，無(wú)藥物過(guò)敏史，無(wú)高血壓、糖尿病病史。無(wú)心、肺疾病史。個(gè)人史：生于原籍，在原籍長(zhǎng)大，生活條件一般。無(wú)毒品接觸史，無(wú)吸煙史，無(wú)飲酒史。月經(jīng)史：月經(jīng)初潮14歲，經(jīng)期持續(xù)4～5天，周期30天，末次月經(jīng)2019年9月1

日?；橛罚何椿槲从?。家族史：父母健在，均體健。醫(yī)師簽名：王××Name:Liu××DateofSurgery:15:26,15thAug.,2019PreoperativeDiagnosis:chronicotitismedia,serousexudationandmicroglandularhyperplasiaIntraoperativeDiagnosis:chronicotitismedia,serousexudationandmicroglandularhyperplasiaNameofOperation:myringotomyandgrommetinsertion(insertionoftransientArmstronggrommettympanostomytube)+glandresectionSurgeon:Wang××AnesthesiaMethod:LocalanesthesiaSurgicalRecords—ChronicOtitisMedia

ProcedureofOperation:Thepatienttooksupineposition.Afteranesthesia,rightexternalauditorycanalwascleanedundermicroscope.Theliquidinaurismediawasabsorbed.Armstronggrommetwasindweltthroughtheincisionandwasrotatedinplace.Anotherearwascleanedandtheliquidinaurismediawasabsorbed.Armstronggrommetwasindweltthroughtheincisionandwasrotatedinplace.Antibioticeardropswereusedforbothearsafteroperation.Afteroperation,thepatientreturnedthewardsafely.Doctor’sSignature:Wang××SuperiorDoctor’sSignature:Li××SurgicalRecords—ChronicOtitisMediaSurgicalRecords—ChronicOtitisMedia手術(shù)記錄—慢性中耳炎姓名：劉××手術(shù)日期：2019-08-15，15:26術(shù)前診斷：慢性中耳炎，漿液性滲出，腺體增生術(shù)中診斷：慢性中耳炎，漿液性滲出，腺體增生手術(shù)名稱(chēng)：鼓膜切開(kāi)置管術(shù)（置入暫時(shí)性Armstronggrommet鼓膜通氣管）+腺體切除術(shù)手術(shù)醫(yī)師：王××麻醉方式：局部麻醉手術(shù)經(jīng)過(guò)：患者仰臥位，麻醉成功后，在顯微鏡下清除右側(cè)外耳道。吸除中耳液體。通過(guò)切口放入Armstronggrommet并旋轉(zhuǎn)到位。清理另一耳朵，吸除中耳液體。通過(guò)切口放入Armstronggrommet并旋轉(zhuǎn)到位。術(shù)后兩耳均使用抗生素滴耳液。術(shù)畢患者安返病房。醫(yī)師簽名：王××上級(jí)醫(yī)師簽名：李××Temperature:36.7℃ Pulse:80bpmRespiratoryRate:18times/min BloodPressure:110/76mmHgGeneralCondition:Thepatient’sdevelopmentwasnormal,withmoderatenutritionandactiveposition.Noyellowstainingwasfoundonskinalloverthebodyandsclera.Superficiallymphnodeswerenottouched.Thesizeofheadwasnormal,withoutdeformationandlump.ENT:Seeresultofspecialconditions.Eyes:Noblepharoptosis,eyelidentropion,hyperemiaandedemaofconjunctivawasfound.Bilateralpupilswereequalandround,andwerereactivetolight.Neck:Theneckwassoft,withoutdistentionofjugularveinandthyromegaly.Thetracheawasinthemiddle.PhysicalExamination—DeviationofNasalSeptumChest:Thethoraxwassymmetricwithoutdeformation.Lung:Vocalfremitusconductionofbothlungswasnormal.Nopleuralfrictionsoundwasfound.Thepercussionsoundswereclear.Therespiratorysoundsofbothlungswereclear,withoutdryandwetrale.Heart:Noprecordialbulgewasfound.Cardiacimpulsewaslocatedat0.5cmwithinleftmid-clavicularlineofthefifthintercostalsregion.Nofremituswastouched.Heartborderwasnotdilatedinpercussion.Heartratewas80bpm,withregularrhythmandwithoutmurmur.Abdomen:Theabdomenwasflat,withoutsubcutaneousvaricoseveinofabdominalwall.Nogastrointestinalandperistalticrushwasfound.Notendernessandreboundtendernesswasfoundallovertheabdomen.Liver,spleenandsubcostalregionwerenottouched.Nopercussionpainwasfoundinhepaticareaandbothrenalareas.Noshiftingdullnesswasfound.Bowelsoundswerenormal.Extremities:Movementofextremitieswasfree.NervousSystem:Physiologicalreflexwasnormal,withoutpathologicalreflex.AnusandExternalGenitalSystem:Notexamined.PhysicalExamination—DeviationofNasalSeptumPhysicalExamination—DeviationofNasalSeptum體格檢查—鼻中隔偏曲體溫：36.7℃ 脈搏：80次/分呼吸：18次/分 血壓：110/76mmHg一般情況：發(fā)育正常，營(yíng)養(yǎng)中等，自動(dòng)體位。全身皮膚、鞏膜無(wú)黃染。淺表淋巴結(jié)未捫及。頭顱大小正常，無(wú)畸形及腫塊。耳鼻喉：見(jiàn)專(zhuān)科情況。眼睛：眼瞼無(wú)下垂、內(nèi)翻，結(jié)膜無(wú)充血、水腫，雙側(cè)瞳孔等大、等圓，對(duì)光反射靈敏。頸部：頸軟，頸靜脈無(wú)怒張，甲狀腺不腫大，氣管居中。胸部：胸廓對(duì)稱(chēng)、無(wú)畸形。肺：雙肺語(yǔ)顫傳導(dǎo)正常，無(wú)胸膜摩擦音，叩診呈清音。雙肺呼吸音清，未聞及干、濕啰音。PhysicalExamination—DeviationofNasalSeptum體格檢查—鼻中隔偏曲心臟：心前區(qū)無(wú)隆起，心尖搏動(dòng)位于第五肋間左鎖骨中線內(nèi)0.5

cm處，未觸及震顫，心界叩診不大。心率80次/分。律齊，無(wú)雜音。腹部：腹部平坦，無(wú)腹壁靜脈曲張。未見(jiàn)胃腸型及蠕動(dòng)波。全腹無(wú)壓痛及反跳痛。肝、脾肋下未觸及，肝區(qū)無(wú)叩痛，雙腎區(qū)無(wú)叩痛。移動(dòng)性濁音陰性，腸鳴音正常。四肢：四肢活動(dòng)自如。神經(jīng)系統(tǒng)：生理反射正常，無(wú)病理反射。肛門(mén)及外生殖系統(tǒng)：未查。思想引領(lǐng)“中國(guó)耳鼻喉領(lǐng)域第一人”韓德民：詮釋一位醫(yī)者的責(zé)任韓德民，中共黨員，中國(guó)工程院院士，世界華人耳鼻喉頭頸外科學(xué)理事會(huì)理事長(zhǎng)，中國(guó)醫(yī)師協(xié)會(huì)耳鼻喉頭頸外科學(xué)分會(huì)會(huì)長(zhǎng)，教育部重點(diǎn)實(shí)驗(yàn)室主任，首都醫(yī)科大學(xué)耳鼻咽喉科學(xué)院院長(zhǎng)，中國(guó)醫(yī)療保健國(guó)際交流促進(jìn)會(huì)會(huì)長(zhǎng)，中國(guó)華夏醫(yī)學(xué)科技獎(jiǎng)理事會(huì)理事長(zhǎng)，世界衛(wèi)生組織防聾合作中心主任，全國(guó)防聾治聾技術(shù)指導(dǎo)組組長(zhǎng)?！斠?jiàn)課本第141頁(yè)課堂小結(jié)這小結(jié)我們學(xué)習(xí)了關(guān)于耳鼻咽喉頭頸外科如何用英語(yǔ)進(jìn)行門(mén)診病歷、入院病例、手術(shù)記錄和檢查報(bào)告的記錄。希望大家在實(shí)踐中能夠