干货 | 如何用英文介绍病情（会诊-床边-PPT）

小白老师说：**A case presentation is a formal communication between doctors regarding a patient’s clinical information. In a case presentation, a doctor presents the details of a patient’s case to colleagues at a clinical meeting in a hospital.

Essential parts of a case presentation include:

病情介绍的要点一般包括：

• Identification
• Reason for consultation/admission
• Chief complaints (CC) - what made patients seek medical attention.
• History of present illness (HPI) - circumstances relating to chief complaints.
• Past medical history (PMHx)
• Past surgical history
• Current medications
• Allergies
• Family history (FHx)
• Social history (SocHx)
• Physical examination (PE)
• Laboratory results (Lab)
• Other investigations (imaging, biopsy etc.)
• Case summary and impression
• Management plans
• follow up in clinic or hospital
• Adherence of the patient to treatment
• success of the treatment or failure
• causes of success or failure

在会诊中介绍病情的语言会比较正式，范例如下：

I’d like to present Mr. Simpson, a 34-year-old plumber, who presented with a one-month history of breathlessness. He also complained of ankle swelling which he’d had for two weeks. There was no relevant past history. He was married with one son. He smoked 25 cigarettes a day and drank about 50 cigarettes a day and drank about units of alcohol per week. His father died of myocardial infarction at the age of 42. His mother was alive and well. On examination, he was obese …

We did a chest X-ray which showed … So we thought he had … We gave him intravenous furosemide and … He responded to treatment and was discharged home.

The above presentation can be divided into the following sections.

Section

Example Language

Introduction

I’d like to present Mr. Simpson,

Patient’s age & occupation

a 34-year-old plumber,

Presenting symptoms and duration

who presented with a one-month history of breathlessness.

Associated symptoms

He also complained of ankle swelling which he’d had for two weeks.

Past medical history

There was no relevant past history.

Social history

He was married with one son. He smoked 25 cigarettes a day and drank about 50 cigarettes a day and drank about units of alcohol per week.

Family history

His father died of myocardial infarction at the age of 42. His mother was alive and well.

Findings on examination

On examination, he was obese …

Investigation results

We did a chest X-ray which showed …

Diagnosis

So we thought he had …

Treatment

We gave him intravenous furosemide and …

Outcome—What happened

He responded to treatment and was discharged home.

Bedside presentation 床边介绍病情

A less formal type of case presentation can take place at a patient’s bed, for example during ward rounds, when the house officer presents a new patient to the consultant; or in a teaching ward round, when a medical student presents a case to the tutor. This type of presentation begins less formally:

有时候我们需要在床边介绍病人的病情，比如在查房过程中，学生向导师介绍病人的病情。这种情况下我们可以的语言不需要太正式。还是刚才Simpson的例子，我们可以这样来介绍：

This is Mr. Simpson. He’s 34, and he’s a plumber. He came into hospital yesterday, sent his GP. He’s complaining of breathlessness, which he’s had for one month …

Slides 幻灯片介绍病情

In a formal presentation, the main points are usually summarized on slides.

在非常正式的会诊中，我们会需要用到PPT，我们可以病情的要点总结到幻灯片上。例如：

Mr. Simpson, 34, plumber

c/o dyspnoea 1/12; anked swelling 2/52

SH married with 1 son

25 cigs / day; 50 units alcohol / week

PH nil relevant

FH father d. 42 MI; mother a & w

OE obese; 2 spider naevi on chest

P 110 / min reg.

BP 100 / 60

CXR enlarged heart and lilat. pleural effusions