《医学英语实用情景教程》（徐青） Unit 2 Surgery 外科

医学英语实用情景教程Unit2Surgery外科知识目标掌握外科常见疾病的英文术语。掌握询问、描述外科常见疾病的相关英文表达。掌握外科英文病历的写法。技能目标能用英语与外科患者沟通。能读懂外科相关的英文病历。思政目标树立“为人民服务、为社会服务、为国家服务”的至高理想，具备“共建健康中国”的意识。项目目标1．学习“知识储备”中的内容，掌握本单元的重点医学术语和常用表达。2．跟读“医患交流”下的英文对话，然后角色扮演各对话场景。3．仔细阅读“病历阅读”下外科相关的英文病历，总结其中重点句型及词汇。4．完成本单元的“任务检测”。5．根据以上任务的完成情况，给自己评分。任务描述目录123知识储备医患交流病历阅读章节导航01知识储备CommonDiseasesofSurgeryKeyWordsandExpressionsModelSentencesCommonDiseasesofSurgery心胸外科myocarditis /ˌmaɪəʊkɑː'daɪtɪs/ 心肌炎congenitalheartdisease(CHD) /kən'dʒenɪt(ə)lhɑːtdɪ'ziːz/ 先天性心脏病rheumaticheartdisease(RHD) /rʊ'mætɪkhɑːtdɪ'ziːz/ 风湿性心脏病acutemyocardialinfarction /ə'kjuːtˌmaɪəʊ'kɑːdɪəlɪn'fɑːkʃ(ə)n/

急性心肌梗死CommonDiseasesofSurgery肝胆外科fattyliver /'fætɪ'lɪvə/ 脂肪肝gallstone /'ɡɔːlstəʊn/ 胆结石pancreatitis /ˌpæŋkrɪə'taɪtɪs/ 胰腺炎hepaticcyst /hɪ'pætɪksɪst/ 肝囊肿hepatichemangioma /hɪ'pætɪkhɪˌmændʒɪ'omə/ 肝血管瘤gallbladdercancer /'ɡɔːlˌblædəˌˈkænsə(r)/ 胆囊癌liverdamage /'lɪvə'dæmɪdʒ/ 肝损伤CommonDiseasesofSurgery脑外科cerebralhemorrhage /'serəbrəl'hemərɪdʒ/ 脑出血hydrocephalus /ˌhaɪdrə'sefələs/ 脑积水meningitis /ˌmenɪn'dʒaɪtɪs/ 脑膜炎concussion /kən'kʌʃn/ 脑震荡cerebralembolism /'serɪbr(ə)l'embəlɪz(ə)m/ 脑栓塞CommonDiseasesofSurgery肠胃外科chronicappendicitis/'krɒnɪkəˌpendɪ'saɪtɪs/慢性阑尾炎0102gastricperforation/'gæstrɪkˌpɜːfə'reɪʃən/胃穿孔CommonDiseasesofSurgery骨科cervicalspondylosis /ˈsəːvɪkəlˌspɔndɪˈləʊsɪs/ 颈椎病periarthritisofshoulder /ˌperɪaː'θraɪtɪsɒv'ʃəʊldə/ 肩周炎osteoproliferation /ˌɒstɪəʊprəuˌlɪfə'reʃən/ 骨质增生osteoporosis /ˌɒstɪəʊpə'rəʊsɪs/ 骨质疏松fracture /'fræktʃə/ 骨折CommonDiseasesofSurgery肛肠外科hemorrhoid/'hemərɔɪd/痔疮01020304rectalcancer/'rekt(ə)l'kænsə/直肠癌analfissure/'eɪn(ə)l'fɪʃə/ 肛裂analfistula /'eɪn(ə)l'fɪstjʊlə/ 肛瘘CommonDiseasesofSurgery泌尿外科prostatitis

/ˌprɒsteɪ'taɪtɪs/

前列腺炎kidneystone

/'kɪdnɪˌstəʊn/

肾结石urethralstone

/jʊ'rɪθrəlˌstəʊn/

尿道结石renaltumor

/'riːn(ə)l'tjuːmə(r)/肾肿瘤CommonDiseasesofSurgery乳腺外科mammaryglandhyperplasia /'mæmərɪglændˌhaɪpə'pleɪzɪə/ 乳腺增生breastcancer /brest'kænsə/ 乳腺癌mastitis /mæ'staɪtɪs/ 乳腺炎KeyWordsandExpressionselbow /ˈelbəʊ/ n. 肘；肘部plastercast /'plɑːstəkɑːst/ 石膏模sling /slɪŋ/ n.（手臂或手受伤时起支撑作用的）悬带discard /dɪsˈkɑːd/ v. 丢弃；抛弃airiness /'eərɪnɪs/ n. 通风bowelmovement /'baʊəlmuːvm(ə)nt/ 排便theruns 腹泻（=diarrhoea）greasy /ˈgriːzɪ/ adj. 油腻的gastrointestinal /ˌgæstrəʊɪn'testɪn(ə)l/ adj. 胃肠的gastriculcer /'gæstrɪk'ʌlsə/ 胃溃疡KeyWordsandExpressionsappendicitis /əˌpendəˈsaɪtɪs/ n. 阑尾炎allergic /ə'lɜːdʒɪk/ adj. 过敏的collaboration /kəˌlæbəˈreɪʃn/ n. 合作；协作appendix /əˈpendɪks/ n. 阑尾abdominal /æbˈdɒmɪnl/ adj. 腹部的ultrasound /ˈʌltrəsaʊnd/ n. 超声inflammation /ˌɪnfləˈmeɪʃn/ n. 发炎；炎症acutemastitis /ə'kjuːtmæ'staɪtɪs/ 急性乳腺炎galactostasis /ˌgælæk'təʊstəsɪs/ n. 乳汁积滞，乳汁淤积abscess /'æbsɪs/ n. 脓肿sucklingperiod /'sʌklɪŋ'pɪərɪəd/ 哺乳期KeyWordsandExpressionssideeffect /saɪdɪˈfekt/ ［常用复数］副作用hotcompress /hɔtkəmˈpres/ 热敷massage /ˈmæsɑːʒ/ n. 按摩educe /ɪ'djuːs/ v. 引出anus /'eɪnəs/ n. 肛门anal /ˈeɪnl/ adj. 肛门的fissure /ˈfɪʃə(r)/ n. 裂缝，裂隙KeyWordsandExpressionsrectalexamination /ˈrektəlɪgˌzæmɪˈneɪʃn/ 直肠指检lump /lʌmp/ n. 肿块；隆起electrocardiogram /ɪˌlektrəʊ'kɑːdɪəgræm/ n. 心电图eyelid /ˈaɪlɪd/ n. 眼睑；眼皮shortsight 近视eyeball /ˈaɪbɔːl/ n. 眼球；眼珠bulgy /'bʌldʒɪ/ adj. 膨胀的，凸出的ModelSentences1.Idislocatedmyelbow.我的手肘脱臼了。2.Myrightarmisswollenandpainful.我的右手臂肿了，特别疼。3.IadviseyoutotakeanX-raytoseeifitisbroken.建议拍张X光片看看是否骨折了。4.I’llfixyourarmwithaplastercastandputyourarminasling.我会用石膏给你的手臂做固定，然后把你的手臂悬吊起来。5.Doyouhavearegularbowelmovementrecently?最近大便正常吗？ModelSentences6.Thebowelmovementisonceadayasusual.大便规律，一天一次。7.Ihavetakentwopillsforthestomachache.However,itdoesn’twork.吃了两粒缓解胃痛的药，但是没有用。8.Areyouallergictoanymedication?你对什么药物过敏吗？9.Doyoufeelbetterlyinghere?你躺着会感觉舒服点吗？10.ThepaingetsworseifItouchthisplace.碰到这里的时候，疼痛会加剧。ModelSentences11.Ifelttiredandsleepy.我觉得浑身无力，而且嗜睡。12.Ihadafeverlastnight.Afterawarmbath,thefeverwasgoneandIfeelbetternow.昨天晚上有点发烧。我洗了热水澡后，就退烧了。现在感觉好点了。13.Howwasthepain?Tingling?Burning?Orswelling?是怎样的疼？刺痛？烧灼般的痛还是有点胀痛？14.Tellmeaboutyourmedicalhistory.Doyouhaveanychronicdiseaseslikeheartdiseaseorhighbloodpressure?你有其他病史吗？比如心脏病、高血压等慢性病。15.NowIhaveaperiod.我现在是月经期。课堂小结这小结我们学习了外科医学中的常见病、关键词和表达式和模型句子。希望大家课下多加复习，加深对英语词汇的理解。02医患交流Conversation1Fracture骨折Conversation2Appendicitis阑尾炎Conversation3AcuteMastitis急性乳腺炎Conversation4Hemorrhoids痔疮Conversation5DoubleEyelidSurgery双眼皮手术Conversation1Fracture骨折D:Howdidyougethurt?P:Ihadabadfallwhenplayingbasketball.Nowtherightarmisswollenandpainful.D:Canyoumoveit?P:No,Ican’t.IthurtswhenItrytomoveit.D:TellmewhereyoufeelpainasIpresshard.(afterexaminingthepatient’sarm)D:IadviseyoutotakeanX-raytoseeifitisbroken.GototheX-rayDepartmentafterpayingthefees.P:OK.(afterhavingtheX-ray)医生：怎么受伤的？患者：我打篮球的时候摔了一跤。现在右手臂肿了，特别疼。医生：右手臂还能动吗？患者：不能，我动的时候手臂很疼。医生：我按压你手臂的时候，哪里痛告诉我。（医生检查完患者手臂后）医生：建议拍张X光片看看是不是骨折了。缴费后去放射科拍片。患者：好的。（拍完X光片后）Conversation1Fracture骨折D:Thepictureindicatesthatyourelbowisbroken.Ineedtofixitincaseyoumoveit.P:Howwillyoufixit?D:I’llfixyourarmwithaplastercastandputyourarminasling.Inthisway,itwillhealsoon.Pleasecomebackinthreeweekstoseeiftheplastercastcanbediscarded.Inthefollowingfourdays,youshouldpaycloseattentiontothebrokenarm.Ifyoufeelanythingabnormal,pleasecomehereintime.P:OK.Thanksalot.Anythingelse?D:Pleasekeeptheplastercastclean.Nowit’shot,makesureyourarmhasgoodairiness.P:Alright.Thanksagain.医生：X光片显示你的手肘确实是骨折了。我需要给它做一下固定，以防止你动到它。患者：怎么固定？医生：我会用石膏给你的手臂做固定，然后把你的手臂悬吊起来。这样你很快就能恢复了。三周后再来复诊，看能否拆除石膏。接下来的4天，你要密切观察受伤的右肘。如有异常，请及时来医院就诊。患者：好的，谢谢医生。还有其他注意事项吗？医生：请保持石膏清洁。现在天气炎热，注意伤肢的通风。患者：好的，谢谢。Conversation2Appendicitis阑尾炎D:Hello,what’sthematter?P:Ihaveastomachache.D:Whendidthepainstart?P:About8p.m.lastnight.D:Canyoutellmetheexactplacewhichhurts?P:Atfirst,itwashere.(Thepatientpointstotheupperbelly.)Andthismorningittransferredtothisplace.(Thepatientpointstotherightlowerpartofhisbelly.)D:Didithurtverymuchlastnight?P:Nottooseriousatfirst.Butitreallyhurtsnow.D:Doyouhavearegularbowelmovementrecently?Doyouhavetheruns?P:It’sregular.AndIdon’thavetheruns.D:Doyouenjoyspicyandgreasyfood?P:Yes,Ilikeitverymuch.医生：你好。你哪里不舒服？患者：我肚子特别痛。医生：从什么时候开始痛的？患者：昨天晚上开始的，大概8点钟吧。医生：能说出具体是哪个位置痛吗？患者：开始的时候是这儿（患者用手指上腹部），今天早晨这儿疼（患者用手指右下腹部）。医生：昨天晚上疼得厉害吗？患者：刚开始还不太严重，现在真的特别疼。医生：最近大便正常吗？腹泻吗？患者：大便规律，也没有腹泻。医生：你平时喜欢吃辛辣、油腻的食物吗？患者：非常喜欢。Conversation2Appendicitis阑尾炎D:

anymedicinebeforecominghere?P:Ihavetakentwopillsforthestomachache.However,itdoesn’twork.D:Didyouhavegastrointestinaldiseasesbefore,likegastriculcerorappendicitis?P:No.Sometimesthestomachwaspainful.Butitgotbetterafterawhile.D:Areyouallergictoanymedication?P:No,I’mnot.D:OK.Pleaseliedownhere.Letmeexamineyourstomach.Relax,please.Itwon’thurtyou.Doyoufeelbetterlyinghere?P:Yes,Ifeelbetter.D:Isthistheplacewhichhurts?P:Yes.医生：来医院前，你自己吃药没？患者：吃了两粒缓解胃痛的药，但是没有用。医生：以前有没有得过肠胃方面的疾病，比如胃溃疡或阑尾炎之类的？患者：没有，以前偶尔腹部会疼，但一般过一会儿就好了。医生：你对什么药物过敏吗？患者：没有。医生：好的，现在请你躺在这儿，我检查下你的腹部。请放松，不用紧张，不会疼的。你躺着会感觉舒服点吗？患者：是的，好一点了。医生：是这里痛吗？患者：是的。Conversation2Appendicitis阑尾炎D:HowdoyoufeelifItakemyhandsawaysuddenlylikethis?P:Itgetsworse.D:Thanksforyourcollaboration.Accordingtotheconversationandexaminationwehadjustnow,Iguessthereissomethingwrongwithyourappendix.Youneedtohavefurtherexaminations.P:WhattestsdoIneedtotake?D:AnabdominalB-modeultrasoundscanandbloodroutine,urineandstooltests.(afterallexaminationresultscomeout)D:Theresultsshowthatyouhaveappendicitisandsurgicaltreatmentisneeded.医生：我这样把手突然松开的话，你感觉如何？患者：更痛了。医生：好的，感谢你的配合。根据刚才我们的交谈和检查，我推测你的阑尾出了点问题。你还要做进一步的检查来确认。

患者：我还要做哪些检查？医生：还需要做一个腹部B超、血常规、尿常规和大便常规。（所有检查结果出来后）医生：你的检查结果表明你患有阑尾炎，需要手术治疗。Conversation2Appendicitis阑尾炎P:CanIjusttakesomemedicine?Iamafraidofsurgery.D:Ifyoudon’ttakesurgicaltreatment,theinflammationwon’tbewellcontrolled,andthatwillresultinariskofinfection.Aftersurgery,youwillrecoversoon.P:OK.Thendoit.D:Pleasesignhere.P:OK.Thanks.D:Youarewelcome.Seeyoulater.患者：能不能就吃点药？我害怕手术。医生：如果不进行手术，炎症得不到有效控制，有感染的风险。手术后，身体很快就会恢复正常的。患者：好吧，那就做手术吧。医生：请在这儿签字确认。患者：好的，谢谢。医生：不谢，一会儿见。Conversation3AcuteMastitis急性乳腺炎P:Doctor,myleftbreastispainfulandswollen.ThepaingetsworseifItouchit.IwanttoaskifIcancontinuetobreast-feedmybaby.D:Whendidyouhavethebaby?P:Twoweeksago.D:Whendidthepainstart?P:Severaldaysago,Ifelttiredandsleepy.ButIdidn’tcareaboutit.Thebreaststartedtohurtyesterday.D:Doestherightonehurttoo?P:No,itdoesn’t.D:Anyotherdiscomfort?P:Ihadafeverlastnight.Afterawarmbath,thefeverwasgoneandIfeelbetternowD:Letmecheckyourbreasts.Andthentakethetemperature.(aftertheexamination)患者：医生，我左侧乳房又疼又胀，碰都不能碰。想问下，我这样还能继续母乳喂养吗？医生：什么时候生的小孩？患者：两周前。医生：从什么时候开始疼的？患者：从几天前开始，我就觉得浑身无力，而且嗜睡。不过一直没在意。昨天乳房开始疼的。医生：右侧乳房疼吗？患者：不疼。医生：还有其他不适没？患者：昨天晚上有点发烧。我洗了热水澡后，就退烧了。现在感觉好点了。医生：我先检查下你的乳房，等会再测体温。（检查完成后）Conversation3AcuteMastitis急性乳腺炎D:Youaresufferingfromacutemastitisresultingfromgalactostasis.Luckily,thefeverwasgoneandthereisnoabscess.Youcanbreast-feedthebabyandyou’dbetterputyourbabytotheleftbreastmoreoftensoastorelievethegalactostasis.P:DoIneedtotakemedicine?D:Noneed.Asyouareinthesucklingperiod,medicinemayhavesomesideeffectsonyourbaby.Herearesomesuggestionsforyou:firstly,dohotcompressonthebreastwithatowel;secondly,massagethebreasttowardsthenippletoeducethebreastmilk;thirdly,washthenippleswithwarmwatertokeepitclean;atlast,haveenoughrestandbeinagoodmood.P:Thanksalot.医生：你这是乳汁淤积引起的急性乳腺炎。不过幸好烧已经退了，而且还没有形成脓肿，你现在可以喂奶，而且要多用患侧乳房喂奶，以减轻乳汁淤积。患者：我需要吃药吗？医生：不用。你现在在哺乳期，药物可能会对婴儿产生副作用。给你几点建议：第一，回去用毛巾热敷患侧乳房；第二，可用手指顺着乳头方向轻轻按摩，帮助乳汁排出；第三，平时要注意保持乳头清洁，常用温水清洗乳头；最后，注意多休息，保持心情愉悦。患者：好的，谢谢医生。Conversation4Hemorrhoids痔疮D:What’swrongwithyou?P:IbledsuddenlytwodaysagowhenIwashavingabowelmovement.AndIfeltsomethingoutsidetheanusafterthat.D:DidyoubleedfromtheP:Iguessitwas.Nottoomuch.Justsomeonthetoiletpaper.D:Wasitpainful?P:Yes.D:Whendidyoufeelthepainusually?Wasthepaincontinuousoroccasional?P:Afterbowelmovements,itcontinuedandoftenlastedforhalfanhour.D:Howwasthepain?Tingling?Burning?Orswelling?P:Swelling.医生：你哪里不舒服？患者：我两天前大便的时候，突然出血，之后还在肛门外摸到了一点儿疙瘩。医生：是从肛门出血吗？量多吗？患者：我想应该是吧。不是很多，厕纸上有一点儿。医生：疼吗？患者：疼。医生：一般什么时候疼？持续痛还是一阵一阵的？患者：大便之后疼。持续疼，一般会疼半个小时。医生：是怎样的痛？刺痛？烧灼般的痛还是胀痛？患者：胀痛。Conversation4Hemorrhoids痔疮D:Whenyouwerewalking,didtheobjectsinyouranuscomeout?P:No,itwouldnot.D:Didyoufeelyouranusswellingoritching?P:No.D:Haveyouhadaregularbowelmovement?Howdoesitlooklike?P:Yes,Ihave.Onceadayanditissoftasusual.D:Haveyouhadafeverrecently?P:No,Ihaven’t.D:Tellmeaboutyourmedicalhistory.Doyouhaveanychronicdiseaseslikeheartdiseaseorhighbloodpressure?P:No,Idon’t.D:Hasanyoneinyourfamilysufferedfromanaldisease?医生：平常走的时候，疙瘩会出来吗？患者：不会。医生：自己有没有觉得肛门处有肿大？或发痒的感觉？患者：没有。医生：最近大便次数正常吗？大便是什么样的？患者：正常，一天一次，是跟以前一样的软便。医生：最近有没有发烧？患者：没有。医生：有其他病史吗？比如心脏病、高血压等慢性病。患者：没有。医生：家族里有没有患过肛门疾病的患者？Conversation4Hemorrhoids痔疮P:Nobody,asfarasIknow.D:Nowpleasetakeyourpantsoff,bendforward,andholdyourupperbodyonthebed.Ineedtoexamineyouranus.P:OK.D:Afissureabout1cmcanbeseenoutsidetheanus.Throughtherectalexamination,Icanfeelmanysoftlumps.Youneedtodomoreexaminations:electrocardiogram(ECG),bloodroutineexaminationandsoon.(aftertheexamination)D:Theresultsshowthatyouhavemixedhemorrhoids.Youshouldbeinthehospitalforfurtherobservationandtreatment.Thenursewillshowyouwhattodonext.P:OK.Thanks.患者：据我所知没有。医生：现在请你脱掉裤子，将上身向前弯曲，把上半身趴在床上，我需要检查下你的肛门。患者：好的。医生：肛门外可以看到一个1cm左右的裂口，指诊可触及多个柔软的肿物。我还需要做一些辅助检查：心电图、血常规等。（检查完成后）医生：检查结果表明你患有混合痔，你需要入院完善各项检查并接受治疗。护士将告诉你下一步该怎么做。

患者：好的，谢谢医生。Conversation5DoubleEyelidSurgery双眼皮手术P:Hello,doctor.I’masingle-eyelidgirl.Ialwaysenvythebigeyesofotherpeople.Itismydreamtohavetwobeautifulbigeyes.Ithinkdoubleeyelidsurgerywillhelpmerealizemydream.D:Doyouknowanythingaboutthissurgery?P:No,itismyfirsttimetoconsult.D:Haveyoutrieddoubleeyelidstickbefore?P:Yes.Ialwaysuseit.That’swhytheskinhereisloose.D:Doyouhaveshortsight?P:Yes.Thelefteye,450degrees;andtherighteye,500degrees.D:Itisalittlebithigh.Areyoupregnantorinthesucklingperiod?P:No,I’mnot.ButnowIhaveaperiod.患者：医生，你好。我是单眼皮。我特别羡慕别人的大眼睛。拥有一双美丽动人的大眼睛是我的梦想。我认为双眼皮手术能帮我实现这个梦想。医生：你之前了解过双眼皮手术吗？患者：没有。这是我第一次咨询。医生：以前贴过双眼皮贴吗？患者：经常贴，所以这里的眼皮有点松弛。

医生：你近视吗？患者：是的。左眼450度，右眼500度。

医生：度数有点高。现在怀孕没？或者在哺乳期吗？患者：没有。不过我现在是月经期。Conversation5DoubleEyelidSurgery双眼皮手术D:Doyouhaveanyspecialrequirementsabouttheeffect?P:Iwishitisnatural.AsIoftendofacialmakeup,Ialsohopethedoubleeyelidisapparent.D:Howisyourphysicalcondition?Isthereinfectionorinflammationaroundyoureyes?Doyouhaveanychronicdiseaseslikehighbloodpressure,diabetes,heartdiseaseandsoon?P:Iamwell.Idon’thavesuchkindofdiseases.D:Alright.Asyouhaveshortsightandtheeyeballsareabitbulgy,Isuggestyouchoosetheburiedlinedoubleeyelidmethod.Andyoucan’thavethesurgerytodaysinceyouareinyourperiod.Youneedtotakesomeexaminationsandmakeasurgicalappointmentaftertheperiod.Donottakeanymedicinewhichcontainsaspirintwoweeksbeforethesurgery.P:Yes.Thankyouverymuch.医生：你对最终的效果有什么特殊要求吗？患者：我希望做完后效果能自然一点。因为我经常化妆，所以还希望双眼皮能明显一点儿。医生：目前身体健康情况如何？眼睛内外是否有感染或炎症？是否患高血压、糖尿病、心脏病等其他慢性疾病？患者：身体健康，没有什么疾病。医生：好的。考虑到你现在近视，且眼球有点凸出，建议你选择埋线重睑法。另外，你现在在月经期，尚不能进行手术。等月经期过去后，再来医院进行相关检查并预约手术。注意手术前两周内，不要服用含有阿司匹林的药物。患者：好的，谢谢您。课堂小结这小结我们学习了如何用英语进行医患交流。希望大家课下多加复习，加深对英语的灵活应用。03病历阅读OutpatientMedicalRecords—LeftBreastNeoplasmAdmissionMedicalRecords(HistoryCollection)—CalculusofBileDuctOperationRecords—Ultra-channelPercutaneousNephrolithotomyPhysicalExamination—GallstoneOutpatientMedicalRecords—LeftBreastNeoplasmChiefComplaint:Thepatientwasfoundwithleftbreastnodulefor3yearsandseveralmonths.HistoryofPresentIllness:3yearsago,thepatientwasfoundwithleftbreastnoduleinphysicalexamination.Thepatientnarratedthatthenodulewastouchableandlocatedatexternallowerquadrantwithasizeofbroadbean,withoutpain.Nonodulewasfoundintherightbreast.Nodischargeofbilateralpapillaewasfound.ColorDopplerultrasoundshowedthatthemasswasnotlarge.Thepatient’sappetiteandspiritwerewell,withpremenstrualsorepainofbothbreasts.Forsurgicaltreatment,thepatientwasadmittedintothehospital.PastMedicalHistory:Nodiseasewasrecorded.PhysicalExamination:Theappearanceoftherightbreastwasnormalwithprotrudingpapilla,withouteczemaontheskin,orangeskinandnippledischarge.Theappearanceoftheleftbreastwasnormalwithprotrudingpapilla,withouteczemaontheskinandorangeskin.OutpatientMedicalRecords—LeftBreastNeoplasmOnenodulewastouchedattheexternallowerquadrantofleftbreast,withgoodactivity,withoutnippledischarge.Noevidentenlargedlymphnodewastouched.AuxiliaryExamination:None.PrimaryDiagnosis:Leftbreastneoplasm.Treatment:1.Furtherexaminationsofbloodroutineexamination,routineurinetest,stoolroutineexamination,liverfunctiontest,kidneyfunctiontest,electrolyteanalysis,bloodglucosetest,bloodlipidtest,screeningofinfectiousdiseasebeforetransfusion,coagulationroutineexamination,ECGandchestradiographyetc.shouldbeperformed.2.Relatedexaminationsshouldbecompleted.Ifthesurgicalcontraindicationisexcluded,performthesurgicaltreatment.Doctor’sSignature:Liu××门诊病历—左侧乳房肿物主诉：左侧乳房结节3余年。现病史：3年前，体检发现左乳结节，患者诉自己可触及，位于外下象限，蚕豆大小，无疼痛。右乳未发现结节。双乳头无溢液。彩超示肿块不大。食欲好，精神状况好，经前双乳肿痛，为求手术治疗，遂入我院治疗。既往史：既往无病史。体格检查：右乳外观正常，乳头凸，皮肤无湿疹，未见橘皮样外观，无乳头溢液。左乳外观正常，乳头凸，皮肤无湿疹，未见橘皮样外观。左乳外下象限可触及一结节，活动度可，无乳头溢液，未触及明显肿大淋巴结。OutpatientMedicalRecords—LeftBreastNeoplasm门诊病历—左侧乳房肿物辅助检查：暂无初步诊断：左侧乳房肿物处理：1．进一步检查血常规、尿常规、大便常规、肝功能、肾功能、电解质、血糖、血脂、输血前传染病筛查、凝血常规等，心电图、胸片等。2．完善相关检查。如无禁忌，行手术治疗。医师签名：刘××OutpatientMedicalRecords—LeftBreastNeoplasmName:Zhu×× Gender:FemaleAge:45yearsold Race:HanOccupation:Other MaritalStatus:MarriedNationality:China NativePlace:××PresentAddress:×××× RepresentorofMedicalHistory:PatientDateofAdmission:8thMar.,2019 Dateofrecord:11:36,8thMar.,2019ChiefComplaint:Thepatienthadintermittentpainofupperabdomenfor20yearsandseveralmonths,withaggravationfor3months.HistoryofPresentIllness:Thepatienthadintermittentpainofupperabdomenduetobiliarytractascariasis(withunknownspecifictreatment)20yearsandseveralmonthsago,withattackfrequencyofonceayear,accompaniedwithfearofcoldness,fever,nauseaandvomitingofgastriccontents.Aftertransfusiontreatment(withunknowndetails)inalocalhospital,thepainwasrelieved.3monthsago,theabdominalpainattackedagainwithprolongedduration.Thepatientvisitedalocalhospitalandcalculusofbileductwasconsidered.AdmissionMedicalRecords(HistoryCollection)—CalculusofBileDuctAfteranti-infectiontreatment,thepainwasalleviated.2daysago,thepainattackedagainandwasrelievedaftertransfusiontreatmentinalocalhospital.Atpresent,forfurtherdiagnosisandtreatment,thepatientvisitedourhospital,andwasadmittedintoourdepartmentfromtheclinicas“calculusofexternalbileduct”.Sincetheonsetofillness,thepatienthashadordinaryspiritandphysicalstrength,normalappetiteandsleep,normalurinationanddefecation,andnoobviousbodyweightchanges.PastMedicalHistory:Thepatientwashealthyinthepastandhadnomedicalhistoryofhypertension,nohistoryofhepatitisorotherinfectiousdiseases.ThepatienthadamedicalhistoryofhypothyroidismandwasregularlytakingThyroidTablets.Nohistoryofoperation,injuryorbloodtransfusion,nohistoryofdrugorfoodallergy.Thepatient’svaccinesweregivenaccordingtothelocalregulations.PersonalHistory:Thepatientwasbornandgrewupinthenativeplaceandhadnohistoryoflivinginotheraforalongtime.AdmissionMedicalRecords(HistoryCollection)—CalculusofBileDuctThepatienthadnohistoryoflivingintheepidemicarea,nohistoryofexposuretoepidemicwaterorepidemicfocus,nohistoryofexposuretoradioactivesubstancesortoxicsubstances,nohistoryofdrugabuse,nohistoryofsmokingordrinking,aswellasnohistoryofimproperrelation.MarriageandChild-bearingHistory:Thepatientismarriedandthepatient’sspouseisingoodhealthandtheygavebirthtoadaughterandason.MenstrualHistory:Thepatient’sageofmenarchewas13,witha4-daymenstrualperiodand45-daycycle.ThedateofthelastmenstrualperiodwasJanuary15,2018.Themenstrualvolumeandcolorwerenormal,withoutbloodclotanddysmenorrhea.Theleucorrheawasnormalandmenstruationwasirregular.FamilyHistory:Thepatient’sparentsarehealthy.Thereisnohistoryofinfectiousdiseasesandhereditarydiseasesinhis/herfamily.Doctor’sSignature:Li××AdmissionMedicalRecords(HistoryCollection)—CalculusofBileDuct入院病历（病史采集）—胆管结石姓名：朱×× 性别：女年龄：45岁 民族：汉职业：其他 婚姻状况：已婚国籍：中国 籍贯：××现住址：×××× 病史陈述者：本人入院日期：2019-03-08 病历记录时间：2019-03-08，11:36主诉：上腹间断疼痛20余年，加重3月。现病史：患者20余年前出现胆道蛔虫（具体治疗不详），后出现上腹疼痛，间断发作，发作频率约为1年1次，疼痛时出现畏寒发热，伴恶心呕吐，呕吐物为胃内容物，至当地医院输液治疗（具体不详）后疼痛可好转。AdmissionMedicalRecords(HistoryCollection)—CalculusofBileDuct入院病历（病史采集）—胆管结石3个月前腹痛再次发作，且持续时间延长，至当地医院就诊，考虑胆管结石，予以抗感染治疗后疼痛好转。2天前疼痛再次发作，于当地医院输液治疗后疼痛好转。今患者为求进一步诊治，遂来我院就诊，门诊以“外胆管结石”收入我科。患病以来，患者精神、体力一般，食欲、睡眠一般，大便正常，小便正常，体重无明显变化。既往史：平素体健，无高血压病史，无肝炎等传染病史。有甲减病史，现规律服用甲状腺片。无手术史，无外伤史，无输血史，无药物过敏史，无食物过敏史，预防接种随当地进行。AdmissionMedicalRecords(HistoryCollection)—CalculusofBileDuct入院病历（病史采集）—胆管结石个人史：生于原籍，在原籍长大，无长期外地居住史，无疫区居住史，无疫水、疫源接触史，无放射物、毒物接触史，无毒品接触史，无吸烟史，无饮酒史，无冶游史。婚育史：已婚，配偶健康状况良好，育有1子1女。月经史：初潮年龄13岁，经期4天，周期45天，末次月经时间2019年1月15

日，经量正常，颜色正常，无血块，无痛经，白带正常，月经不规律。家族史：父母健在，家族中无传染病及遗传病史。医师签名：李××AdmissionMedicalRecords(HistoryCollection)—CalculusofBileDuctName:Zhang××DateofSurgery:11thApr.,2019PreoperativeDiagnosis:RenalcalculusIntraoperativeDiagnosis:RenalcalculusNameofOperation:Ultra-channelPercutaneousNephrolithotomySurgeon:Zou××Anesthetist:Zhou××CirculatingNurse:Hu××AnesthesiaMethod:GeneralanesthesiaProcedureofOperation:1.Lithotomypositionwasused.Complexiodinewasusedfordisinfectionofperineum.Drapingwasperformed.Ureteroscopesmoothlyenteredurethra,showingbenignprostatichyperplasia.Mildhyperemiaandedemaofbladdermucosawerefound.Urinewasturbidwithfloatingfloccules.Urethralcatheterwasretrogradeindweltontheoperationside.OperationRecords—Ultra-channelPercutaneousNephrolithotomy2.Thepatientwasshiftedtoaproneposition.Onesmallpillowwascushionedunderanteriorthoracicregion,abdomenandkneejointsrespectively.3.Thejunctionbetweenthe12thsubcostalandposterioraxillarylineoftheaffectedsidewasselectedasthepuncturepoint.4.PunctureintotargetkidneyandlowercalyxunderguidanceofBultrasoundwasperformed.Turbidurinewasdischargedwhenthestyletwaspulledout.5.0.032inchZebraUrologicalGuidewirewasinsertedthroughpunctureneedlesheath.Theskinandfasciawerecutbyaround1cmwithaknifealongthepunctureneedle.TheneedlesheathwaswithdrawnandZebraUrologicalGuidewirewasretained.6.ChanneldilationwasstartedfromFr8byfasciadilatoralongtheguidewiretowardskidney,andwasincreasedgraduallytoFr12.Fr12dilatorwasscrewedintogetherwithcorrespondingoperatingsheath.OperationRecords—Ultra-channelPercutaneousNephrolithotomy7.Thedilatorwasretreated.Fr8superfinenephroscopewasinsertedintorenalcollectionsystemthroughthesheath.Thecalculifoundwerein(lightyellowandblackbrown)with(hard,crispyandmuddymoss-liked)texture,completelyfillingrenalcollectionsystem.Thecalculiwerecrushedandremovedbyholmiumlasermethod.Kidneyandopeningofureterweredetected,showingevidentedemaofsuperiorsegmentofureter,pelvisandmucosaofrenalcalyx,formationofpolypusofureterandturbidurine.8.Inreexamination,noresidualcalculuswasfoundinpelvis,renalcollectionsystemandsuperiorsegmentofureter.ZebraUrologicalGuidewirewasantegradeindwelt,underwhichguidanceoneF4.8DJtubewasretained.OperationRecords—Ultra-channelPercutaneousNephrolithotomy9.CorrespondingF10urethralcatheterswereinsertedintorenalcollectionsystemthroughsheath,andthesheathwaswithdrawnwhendrainagewasconfirmedtobeunobstructed.10.No.4wirewasusedtosuturetheskinincisionandtofixnephrostomytube.Theextractedendwasconnectedwiththeopeningofurinecollectionbag.Surgeon’sSignature:Yang××SignaturebySuperiorDoctor:Zou××OperationRecords—Ultra-channelPercutaneousNephrolithotomyOperationRecords—Ultra-channelPercutaneousNephrolithotomy手术记录—超微通道经皮肾镜碎石术姓名：张××手术日期：2019-04-11术前诊断：肾结石术中诊断：肾结石手术名称：超微通道经皮肾镜碎石术手术医师：邹×× 麻醉师：周×× 巡回护士：胡××麻醉方式：全身麻醉手术经过：1．取截石位，络合碘消毒会阴部，铺巾，输尿管镜顺利进入尿道，见前列腺增生，膀胱黏膜轻度充血、水肿，尿液混浊、有絮状物漂浮。逆行留置术侧导尿管导管。OperationRecords—Ultra-channelPercutaneousNephrolithotomy手术记录—超微通道经皮肾镜碎石术2．改俯卧位，胸前区、腹部下、膝关节下各垫一小枕。3．选患侧第12肋下与腋后线交界处为穿刺点。4．在B超引导下穿刺进入目的肾中、下盏内，拔出针芯，有混浊尿液流出。5．通过穿刺针鞘引入0.032英寸斑马导丝，小尖刀沿穿刺针切开皮肤及筋膜约1cm，退出针鞘留下斑马导丝。6．由Fr8开始，将筋膜扩张器沿导丝向肾作通道扩张，逐渐增大至Fr12，将Fr12扩张器连同相应操作鞘一起旋入。7．退出扩张器，将Fr8超细肾镜从鞘内进入肾集合系统。见结石呈（淡黄、黑褐色），质（硬、脆、泥苔样），完全充填肾集合系统，用钬激光方法将结石击碎取出，探查肾及输尿管开口，输尿管上段、肾盂、肾盏黏膜明显水肿，输尿管息肉形成，尿液混浊。OperationRecords—Ultra-channelPercutaneousNephrolithotomy手术记录—超微通道经皮肾镜碎石术8．复查各肾盂及集合系统、输尿管上段未见残石，顺行留置斑马导丝，并在其引导下留置F4.8DJ管一根。9．放置相应的F10导尿管从管鞘内插入肾集合系统内，确定引流通畅，将鞘退出。10．4号丝线缝合皮肤切口并固定肾造瘘管，引出端接集尿袋开放。手术医师签名：杨××上级医师签名：邹××Temperature:36.5℃ Pulse:80bpm RespiratoryRate:20bpmBloodPressure:120/76mmHgThepatienthadnormaldevelopment,moderatenutrition,chronicdiseaseappearance,activeposition,sanity,normalgaitsandwascooperativewhilebeingexamined.Therewasnoyellow-stainingofskinandsclera,andnosuperficiallymphnodesweretouched.Theskullshowednormalsizewithoutmalformationormass,andthefivesenseorganswerewell-featured.Thepalpebralconjunctivashowednoedema.Thebilateralpupilswereroundandequalinsizewiththediameterofabout3mmandwithsensitivelightreflex.Therewasnomalformationofauriculae,noexudationofexternalauditorycanals,noflaringofnaresandnosecretainthenasalcavities.Thebuccalmucosawasruddyandtheoralmucosashowednoulcerorbleeding,thepharynxshowednocongestionandthebilateraltonsilswerenotenlarged.Theneckwassoftwithoutdistentionofjugularvein,thetracheawascenteredandthethyroidglandswerenotenlarged.PhysicalExamination—GallstoneThethoraxesweresymmetricalwithoutmalformation,thevocalfremitusconductionandthebreathsoundofbilaterallungswerenormal,therewasresonanceonpercussionwithoutdr