《醫(yī)學英語實用情景教程》（徐青） Unit 7 Otorhinolaryngology,Head and Neck Surgery 耳鼻咽喉頭頸外科

醫(yī)學英語實用情景教程Unit7Otorhinolaryngology,HeadandNeckSurgery

耳鼻咽喉頭頸外科知識目標掌握耳鼻咽喉頭頸外科常見疾病的英文術語。掌握詢問、描述耳鼻咽喉頭頸外科常見疾病的相關英文表達。掌握耳鼻咽喉頭頸外科英文病歷的寫法。技能目標能用英語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的英文病歷。思政目標強化勇挑重擔，為祖國醫(yī)療衛(wèi)生事業(yè)發(fā)展貢獻力量的意識。項目目標1．學習“知識儲備”中的內容，掌握本單元的重點醫(yī)學術語和常用表達。2．跟讀“醫(yī)患交流”下的英文對話，然后角色扮演各對話場景。3．仔細閱讀“病歷閱讀”下耳鼻咽喉頭頸外科相關的英文病歷，總結其中重點句型及詞匯。4．完成本單元的“任務檢測”。5．根據(jù)以上任務的完成情況，給自己評分。任務描述目錄123知識儲備醫(yī)患交流病歷閱讀章節(jié)導航01知識儲備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 主覺性耳鳴chroniclymphadenitis/?kr?n?kl?m?f?d??na?t?s 慢性淋巴結炎

CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryatrophicrhinitis /?'tr?f?kra??na?t?s 萎縮性鼻炎allergicrhinitis /??l??d??kra??na?t?s 變應性鼻炎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，聲帶結節(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；溫度計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 聽力減退，聽力損耗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inaccordancewith 與……一致，依照specification /?spes?f??ke??n/ n.

明細單；說明書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)嚴重發(fā)炎了，口腔內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.我對任何抗生素都不過敏。ModelSentences5.Doyoubreathewellwhensleeping?你睡覺的時候呼吸是否通暢？6.Surgicaloperationisthemosteffectivewaytocurethedisease.手術是治愈這種病最有效的方法。8.AnX-rayscanofyournoseshouldbedonetoseeifthereisafracture.你需要去做一個X光掃描來看看鼻骨是不是骨折了。7.Takethemedicineinaccordancewiththespecification.按照說明書服用給你開的藥。ModelSentences9.Doyousleepwell?Andwhatothersymptomsdoyouhave?你睡得好嗎？還有沒有其他癥狀？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，所以沒有充足的高質量睡眠。11.I’llopenyournasalcavitywithaspeculumandthenuseaflashlighttolookinsideyournose.我要用擴張器打開你的鼻腔，然后用手電筒看看你的鼻子內部。ModelSentences13.Cervicalspondylosisisprobablycausedbythepoorposturewithprolongedsittingandlotsofstress.頸椎病很可能是不良姿勢的久坐和巨大壓力引起的。14.Doingdailyneckexerciseswillhelpyourecoverfromcervicalspondylosis.每天做頸椎運動有助于你的恢復。課堂小結這小結我們學習了耳鼻咽喉頭頸外科醫(yī)學中的常見病、關鍵詞和表達式和模型句子。希望大家能加深對英語詞匯的理解并靈活應用。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，你臉色看起來有點黃。這幾天飲食正常嗎？患者：不正常，我最近胃口不好。因為吞咽困難，我只能吃一些流質食物，有時候還想吐。醫(yī)生：明白了。那你從什么時候開始有這個癥狀的？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：請把這根體溫計含在舌下。（幾分鐘后）你有點發(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，你用棉簽按壓時痛。醫(yī)生，我這是怎么了？嚴不嚴重呀？醫(yī)生：你的喉嚨已經(jīng)嚴重發(fā)炎了，口腔內壁及咽喉表面均因感染而生紅?？磥砟氵@是得了急性扁桃體炎?；颊撸哼@種病會傳染，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。但是不用這么難過，我給你開些藥，你很快就會恢復。你對抗生素過敏嗎？患者：我對任何抗生素都不過敏。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，一會兒見。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，聽力也下降了。醫(yī)生：鼻涕里帶血嗎？患者：是的，有時候帶血。醫(yī)生：你睡覺的時候呼吸是否通暢？患者：不是很通暢，幾乎要喘不過氣來了，而且半夜咳嗽得很厲害。醫(yī)生：這樣的癥狀持續(xù)多長時間了？患者：已經(jīng)超過一年了。醫(yī)生：你應該先做個血液檢測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。我很快會拿著檢查結果再過來。到時候見。（檢查結果出來后）醫(yī)生：根據(jù)檢查結果，你得的是鼻咽癌。患者：這太可怕了！我該怎么辦？醫(yī)生：不用擔心，我會給你開些藥來幫你控制病情。如果病情控制住了，就可以進行手術。手術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：你對什么藥物過敏嗎？患者：沒有，之前沒有過敏過。醫(yī)生：好了。按照說明書服用給你開的藥?；颊撸悍浅８兄x。醫(yī)生：不客氣，希望你盡快康復。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，我的鼻子嚴重挫傷。太疼了。醫(yī)生：讓我仔細檢查一下?；颊撸壕褪沁@兒！哎呦，我的鼻子！醫(yī)生：你需要去做一個X光掃描來看看鼻骨是不是骨折了。（做完X光后）是的，是骨折。患者：你可以給我開點止疼藥緩解一下疼痛嗎？醫(yī)生：你對什么藥品過敏嗎？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。患者：這藥真的有效果嗎？醫(yī)生：有效果。給你。上面的說明會告訴你怎么服用，一定得看仔細了?；颊撸褐x謝你的提醒。醫(yī)生：希望你早日康復?；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，白天感覺太疲憊以至于無法專心工作。醫(yī)生：你睡得好嗎？還有沒有其他癥狀？患者：我睡眠質量不好，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：請坐下，放松。我要用擴張器打開你的鼻腔，然后用手電筒看看你的鼻子內部?；颊撸汉玫?。（5分鐘過后）醫(yī)生：哦，你可能患有慢性鼻竇炎。你之前在醫(yī)院做過鼻部CT檢查嗎？患者：沒做過。醫(yī)生：嗯，你必須做一個鼻部CT掃描來確認慢性鼻竇炎的診斷。Conversation4ChronicSinusitis慢性鼻竇炎P:Noproblem.D:ComebackwithyourexaminationresultsandIwillprescribeyousomemedication.P:Thanksalot.Seeyouthen.D:Seeyou.患者：沒問題。醫(yī)生：帶上你的檢查結果回來，到時候我會給你配些藥?；颊撸悍浅８兄x您，一會兒見。醫(yī)生：一會兒見。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。這些天我脖子有點痛。醫(yī)生：你覺得脖子僵硬嗎？患者：是的，有點。醫(yī)生：你是做什么工作的？患者：我是個程序員，周一到周六都需要工作，工作時間特別長。醫(yī)生：你睡得好嗎？患者：我很難入睡，所以沒有充足的高質量睡眠。醫(yī)生：請?zhí)上拢潘杉∪?，讓我檢查一下。我按壓這里的時候疼嗎？患者：是的，很疼。請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?；颊撸号叮裁磿疬@種??？醫(yī)生：有很多因素可以引起這種病。但對你來說，可能是不良姿勢的久坐和巨大壓力引起的。患者：那你能幫我開些藥來緩解脖子的痛嗎？醫(yī)生：當然可以。此外，每天做頸椎運動有助于你的恢復。

患者：好的，謝謝醫(yī)生。課堂小結這小結我們學習了如何用英語進行醫(yī)患交流。希望大家課下多加復習，加深對英語的靈活應用。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門診病歷—急性化膿性扁桃腺炎主訴：吞咽痛伴發(fā)熱3天?，F(xiàn)病史：患者發(fā)病以來吞咽疼痛，伴發(fā)熱、頭痛、全身乏力。無張口困難，無寒戰(zhàn)、抽搐，無呼吸困難。既往史：平素體健，無藥物過敏史，無高血壓、糖尿病病史，無心、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門診病歷—急性化膿性扁桃腺炎輔助檢查：血常規(guī)：白細胞（WBC）7.2×109/L，血小板（PLT）48×109/L，淋巴細胞百分比（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：未婚國籍：中國 籍貫：××現(xiàn)住址：×××× 病史陳述者：本人入院日期：2019-09-17 病歷記錄時間：2019-09-17，17:00主訴：鼻塞，鼻內有膿性分泌物，持續(xù)9年?，F(xiàn)病史：患者9年前無明顯誘因鼻內有膿性分泌物，鼻塞。無發(fā)熱、頭暈和頭痛等不適。當?shù)蒯t(yī)院診斷為“鼻中隔偏曲”，建議手術，因經(jīng)濟原因選擇藥物治療（具體不詳）?，F(xiàn)患者欲手術，來我院就診，門診以“鼻中隔偏曲”收入我科。患病以來，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，無藥物過敏史，無高血壓、糖尿病病史。無心、肺疾病史。個人史：生于原籍，在原籍長大，生活條件一般。無毒品接觸史，無吸煙史，無飲酒史。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。婚育史：未婚未育。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手術記錄—慢性中耳炎姓名：劉××手術日期：2019-08-15，15:26術前診斷：慢性中耳炎，漿液性滲出，腺體增生術中診斷：慢性中耳炎，漿液性滲出，腺體增生手術名稱：鼓膜切開置管術（置入暫時性Armstronggrommet鼓膜通氣管）+腺體切除術手術醫(yī)師：王××麻醉方式：局部麻醉手術經(jīng)過：患者仰臥位，麻醉成功后，在顯微鏡下清除右側外耳道。吸除中耳液體。通過切口放入Armstronggrommet并旋轉到位。清理另一耳朵，吸除中耳液體。通過切口放入Armstronggrommet并旋轉到位。術后兩耳均使用抗生素滴耳液。術畢患者安返病房。醫(yī)師簽名：王××上級醫(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，營養(yǎng)中等，自動體位。全身皮膚、鞏膜無黃染。淺表淋巴結未捫及。頭顱大小正常，無畸形及腫塊。耳鼻喉：見?？魄闆r。眼睛：眼瞼無下垂、內翻，結膜無充血、水腫，雙側瞳孔等大、等圓，對光反射靈敏。頸部：頸軟，頸靜脈無怒張，甲狀腺不腫大，氣管居中。胸部：胸廓對稱、無畸形。肺：雙肺語顫傳導正常，無胸膜摩擦音，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)無隆起，心尖搏動位于第五肋間左鎖骨中線內0.5

cm處，未觸及震顫，心界叩診不大。心率80次/分。律齊，無雜音。腹部：腹部平坦，無腹壁靜脈曲張。未見胃腸型及蠕動波。全腹無壓痛及反跳痛。肝、脾肋下未觸及，肝區(qū)無叩痛，雙腎區(qū)無叩痛。移動性濁音陰性，腸鳴音正常。四肢：四肢活動自如。神經(jīng)系統(tǒng)：生理反射正常，無病理反射。肛門及外生殖系統(tǒng)：未查。思想引領“中國耳鼻喉領域第一人”韓德民：詮釋一位醫(yī)者的責任韓德民，中共黨員，中國工程院院士，世界華人耳鼻喉頭頸外科學理事會理事長，中國醫(yī)師協(xié)會耳鼻喉頭頸外科學分會會長，教育部重點實驗室主任，首都醫(yī)科大學耳鼻咽喉科學院院長，中國醫(yī)療保健國際交流促進會會長，中國華夏醫(yī)學科技獎理事會理事長，世界衛(wèi)生組織防聾合作中心主任，全國防聾治聾技術指導組組長。……詳見課本第141頁課堂小結這小結我們學習了關于耳鼻咽喉頭頸外科如何用英語進行門診病歷、入院病例、手術記錄和檢查報告的記錄。希望大家在實踐中能夠