临床带教与英文查房 | 胆石症（二）
摘要： 胆石症（Gallstone Disease）是指胆囊或胆管内形成结石所引起的一系列临床综合征，常见并发症包括急性胆囊炎、胆总管梗阻及胰腺炎。Murphy征阳性是急性胆囊炎的重要体征，表现为深吸气时因肿大胆囊触碰检查者手指而引发疼痛并中断吸气。临床带教结合英文查房有助于医学生和住院医师掌握规范的病史采集、体格检查及专业术语表达。
- Murphy征阳性是诊断急性胆囊炎的关键体征，其机制与深吸气时肝脏下移使发炎胆囊接触按压点有关。
- 胆石症可引发多种并发症，如胆总管结石、胆源性胰腺炎等，需结合症状（如发热、黄疸）综合判断。
- 床边教学（Bedside teaching）在培养医学生临床技能和专业英语沟通能力方面具有不可替代的作用。
- 规范的腹部查体流程有助于快速识别胆囊疾病，并为后续影像学和手术决策提供依据。
小白老师说：Bedside teaching is seen as one of the most important modalities in teaching a variety of skills for the medical profession, which greatly improves certain clinical diagnostic skills in medical students and residents.
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Gallstone Disease 胆石症（二）
Ill. Examination 体检
Intern: Mrs. Jones, please tell me where it hurts when I tap on your abdomen.
实习医师甲张太太，在我轻按你腹部时，请告诉我哪里痛。
Patient: Oh, it really hurts now.
病人：哦，你现在按的地方就很痛。
Intern: Sorry. What about the lower part?
实习医师：那么下面一点的地方痛吗?
Patient: Err, not too bad.
病人：嗯······ 倒不是很厉害。
**Intern：**Mrs. Jones, I’m going to place my hand below your rib cage here. Does it hurt when I press here?
实习医师：张太太，现在我把手放在你肋下。我按这里时，你觉得痛吗?
**Patient：**It’s sore, but I can stand it.
病人：痛的，但我能忍受。
Intern: OK. Now please take a deep breath.
实习医师：好的，现在请深呼吸。
Patient: Wow! That hurts! I can’t breathe any more.
病人：噢，很疼。我不能深呼吸。
Chief physician: Well, as Dr. Clark has told us that she had a positive Murphy’s sign. Dr. Grey, please tell us the significance of it.
主任医师：正如 Clark 医生刚才所说的，该病人Murphy 征阳性。Grey 医生，请你说一下它的是什么意思。
Intern: It reflects an inflammation in the gallbladder.
实习医师：这说明胆囊有炎症。
Chief Physician: Right. Could you explain it briefly?
主任医师：对。能简单说明一下吗?
Intern: Yes. I used my thumb pressing the intersection of the right midclavicular line ( MCL ) and the costal arch. When the patient breathed deeply, it brought the liver down and the swelling gallbladder hit my fingers, causing a strong pain and halted the deep breath. Since the gallbladder is attached to the undersurface of the liver, tenderness rarely exists unless there’s an inflammation.
实习医师：好。我用拇指按压右锁骨中线 (MCL) 和肋弓的交界点，当病人深吸气时，带动肝脏下移，我的手指就能触碰到肿大的胆囊，引起剧烈的疼痛，吸气被迫中止。由于胆囊附着于肝脏底面，如果不发炎一般是不会引起触痛的。
Chief Physician: Good job. Mrs. Jones, the physical examination has made me even more convinced that you have a gallbladder problem. In fact, you may have an inflammation of the gallbladder. We call this acute cholecystitis.
主任医师：答得好。腹部体检的体征支持胆囊疾病。张太太，你的胆囊可能有炎症，也就是急性胆囊炎。
Patient: Do I need an operation once more?
病人：那我还需要做手术吗?
Chief Physician: Definitely. Furthermore, you have got a fever and jaundice. It’s possible that you have more problems, a stone blocking your common bile duct and another stuck in your cystic duct. Another possibility is that one stone might have passed through your papilla of Vater and developed an inflammation of your pancreas, a condition called pancreatitis.
主任医师：是的，而且你还有发热和黄疸，说明你的问题也许更为严重。结石可能已堵住了你的胆总管，或卡在胆囊管里。还有一种情况就是，结石可能经过乏特壶腹乳头，引起胰腺发炎，称为胰腺炎。
Patient: Gosh, it’s surely more complicated than the appendicitis that I have had.
病人：糟了，这可比阑尾炎严重多了!
Chief Physician: Exactly, but we can sort it all out and get you well. All right, thank you for cooperation. We’ll make arrangement for you soon.
主任医师：是的，那肯定，但我们能够解决问题，你会康复的。谢谢你的配合，我们会尽快安排手术的。
Patient: OK, thank you very much!
病人：好的，非常感谢！
常见问题
什么是Murphy征？它在胆石症诊断中有何意义？
Murphy征是指检查者将手置于患者右锁骨中线与肋弓交界处，嘱患者深吸气，若因胆囊炎症导致触痛而突然屏住呼吸，则为阳性。它是急性胆囊炎的重要临床体征。
胆石症患者出现黄疸和发热提示什么？
提示可能存在胆总管结石或胆道梗阻，甚至并发胆管炎或胰腺炎，需进一步影像学评估和紧急处理。
为什么临床带教中强调英文查房？
英文查房有助于医学生和住院医师在真实临床场景中掌握专业英语表达、规范问诊流程，并提升国际交流能力。