白袍Clarkの知識充電站

作者: blue (健康就好) 看板: Medicine_92

  今天morning meeting請了一個外國醫師來教大家病例的書寫方式
  她是一位已在台灣行醫30年的內科醫師
  他特別針對馬偕醫院病例書寫上的缺失及常見的台灣式英文寫法提出建議
  並拿出實際例子作修正
  我和妙子聽了都感到十分震撼
  因為他所舉出的例子,"每一個"我們平常都用的不亦樂乎
  在此特別提出來供大家參考
  其中有些並不是文法上的錯誤
  但這位外國醫師說,聽起來就是覺得不舒服,She never heard that in America
  大家有空就花點時間看看吧
  別讓老外笑我們英文差

  Avoid these phrases   --> Possible alternatives

  Dx was highly suspected   --> We strongly suspected dx.
                               Ther most likely diagnosis was thought to be.

  Under the impression of dx --> The pt was admitted with suspected dx
                                 The admitting diagnosis was dx
                                 She was admitted for evaluation of possible dx
  註: 在美國沒聽過這種說法,不知是哪個學長姐發明的而被發揚光大

  We highly favor/prefer dx  （聽起來像是你很希望有某疾病 )

                              --> The evidience favors dx.
                                  Dx is most likely.
                                  She probably has dx.

Dx was told to the pt   --> The p't was told she had dx.
                            We informed the pt of her diagosis.

Body weight (loss)/ temperature   --> weight (loss)/ temperature

According to the statement of the pt...
                                    --> According to the pt... [ ok ]
                                        The pt said... [ better ]

Tracing back the history...  --> The pt had a history of ...
                                 There was a history of...
   註:這句也是台灣人自創的喔:) 她說trace的感覺像是很仔細的去找尋...

The pt is a victim of dx   --> The pt has dx.
   註:病例上盡量不要出現帶有感情的字眼,如victim, suffer,...
        她主張直接把關懷表現在對病人的態度上

R/O  -- technically, this is a plan indication we want to exclude a
        certaion dx.

                             --> Dx is suspected
                                 Dx is unlikely.

The pt suffered from...   --> The pt had...

S/P      --> S/P [precedure]

over ( indicationg an abnormality in a specific location )
         感覺像是該abnormality在該location的上方
            --Use "in" or "on"
                                                                             \
Three days ago, the pt...   --> three days prior to admission, the pt...

She received an operation  --> She had an operation.
                                She underwent a [procedure].
                                Surgery was performed.
註: receive: 接受而獲得某物, 用在這裡怪怪的
              事實上,病人在手術後只得到一個scar

[Study] was arranged.   --> [Study] done on [date] showed...
                             A [study, procedure, therapy] was planned, but
                               the pt ...

  The pt didn't pay attention to... --> The pt ignored...
                                        [ Symptoms ], but she ignored it.
                                        It didn't bother her enough to...

Do not use !! 切記!!

   The pt is a case of dx.    註: a person is not a thing.
                                  --> The pt has dx.
                                      This is a case of dx.

  This is a patient of dx.   --> The pt has dx.
                                 This is a pt with dx.

  The case expired.        --> The pt died.
        註: 1. 病人會死亡,但case本身並不會死去
            2. 用expired 並不會使死亡這個事實的感覺變的較好

  She ever had syncope.   --> She has had one episode of syncope.
      註: "Ever" in English is usually used only in imperatives
             [ Dont' you ever do that again!]
              or questions [ Have you ever fainted?]
             Possible answers to that question might be "never", "once"

          "often" etc. We do not say, " Yes, I ever fainted."

Dx was impressed.   --> Dx was suspected.
                        We suspected dx.
                        Our initial [diagnostic] impression was dx.
   註: impress 是指印象深刻

Suicided    --> She committed suicide.
                       ( = She succeeded, and she is dead. )
                She attempted suicide.
                       ( = She failed, and she is still alive. )

Bilateral arms/lungs/kidneys, etc  --> Both arms/lungs/kidneys, etc.

註:  "Bilateral" as an adjective is used only to describe abnormal lesions,
         eg. bilateral infiltrates, bilateral hydronephrosis, etc
       The adverb form "bilaterally" can refer to normal or abnormal findings
       - it modifies the verbs, not the noun.
         The breath sounds were clear bilaterally.
         She had ankle edema bilaterally.

其他可能引起誤會的用法:
Vital signs were stable.

    註: Stable 不等於 Normal
         eg. PR: 0, RR:0, BP:0/0, T:23C
             Vital signs are very stable.:)

RHB, no murmurs
    註: 同上, regular rhythm 不一定正常,可能為PSVT...

Regular medical control: Taking medicine 不等於 Control
    註: This usually means only that the pt regularly comes
          to the OPD for medication refills. But the "degree"
         of control is what's important.