《医学英语实用情景教程》（徐青） Unit 7 Otorhinolaryngology,Head and Neck Surgery 耳鼻咽喉头颈外科

医学英语实用情景教程Unit7Otorhinolaryngology,HeadandNeckSurgery

耳鼻咽喉头颈外科知识目标掌握耳鼻咽喉头颈外科常见疾病的英文术语。掌握询问、描述耳鼻咽喉头颈外科常见疾病的相关英文表达。掌握耳鼻咽喉头颈外科英文病历的写法。技能目标能用英语与耳鼻咽喉头颈外科患者沟通。能读懂耳鼻咽喉头颈外科相关的英文病历。思政目标强化勇挑重担，为祖国医疗卫生事业发展贡献力量的意识。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”下耳鼻咽喉头颈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CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryKeyWordsandExpressionsModelSentencesCommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryotitismedia /əʊˈtaɪtɪsˈmiːdɪə 中耳炎耳部疾病subjectivetinnitus/səbˈdʒektɪvˈtɪnɪtəs 主觉性耳鸣chroniclymphadenitis/ˈkrɒnɪklɪmˌfædɪˈnaɪtɪs 慢性淋巴结炎

CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryatrophicrhinitis /æ'trɒfɪkraɪˈnaɪtɪs 萎缩性鼻炎allergicrhinitis /əˈlɜːdʒɪkraɪˈnaɪtɪs 变应性鼻炎nasalpolyp /ˈneɪzlˈpɒlɪp 鼻息肉deflectionofnasalseptum /dɪˈflekʃnəvˈneɪzlˈseptəm 鼻中隔偏曲epistaxis /ˌepɪˈstæksɪs 鼻衄，鼻出血nasosinusitis /nəsəʊzaɪˈnəsaɪtɪs 鼻窦炎chronicsinusitis /ˈkrɒnɪkˌsaɪnəˈsaɪtɪs 慢性鼻窦炎cystofnasalsinus /sɪstəvˈneɪzlˈsaɪnəs 鼻窦囊肿鼻部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgerynasalvestibularcyst /ˈneɪzlveˈstɪbjʊləsɪst 鼻前庭囊肿nasopharyngealcarcinoma /ˌneɪzəʊfəˈrɪndʒɪəlˌkɑːsɪˈnəʊmə 鼻咽癌nosebonefracture /nəʊzbəʊnˈfræktʃə(r)/ 鼻骨骨折pharyngitis /ˌfærɪnˈdʒaɪtɪs 咽炎asthmaticbronchitis /æsˈmætɪkbrɒŋˈkaɪtɪs 哮喘性支气管炎hyperplasticpharyngitis /ˌhaɪpəˈplɑːtɪkˌfærɪnˈdʒaɪtɪs/ 肥厚性咽炎，增生性咽炎pharyngitissicca /ˌfærɪnˈdʒaɪtɪsˈsɪkə 干燥性咽炎acutetonsillitis /əˈkjuːtˌtɒnsəˈlaɪtɪs 急性扁桃体炎咽部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgeryadenoidhypertrophy /ˈædɪˌnɔɪdhaɪˈpɜːtrəfɪ 腺样体肥大pharyngealparaesthesia /fəˈrɪndʒɪəlˌpærɪsˈθiːzɪə 咽异感症obstructivesleepapneahypopneasyndrome /əbˈstrʌktɪvsliːpˈæpnɪəhaɪ'pɒpnɪəˈsɪndrəʊm/ 阻塞性睡眠呼吸暂停低通气综合征vocalnodule /ˈvəʊklˈnɒdjuːl 声带小结，声带结节polypofvocalcord /ˈpɒlɪpɒvˈvəʊklkɔːd 声带息肉咽部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgerychroniclaryngitis /ˈkrɒnɪkˌlærɪnˈdʒaɪtɪs 慢性喉炎laryngealarthritis /ləˈrɪndʒɪəlɑːˈθraɪtɪs 喉关节炎laryngospasm /lə'rɪŋɡəspæzəm 喉痉挛functionalaphonia /ˈfʌŋkʃənlæˈfəʊnɪə 功能性失声benigntumoroflarynx /bɪˈnaɪnˈtjuːmə(r)əvˈlærɪŋks 喉良性肿瘤laryngealedema /ləˈrɪndʒɪəlɪˈdiːmə 喉头水肿喉部疾病CommonDiseasesofOtorhinolaryngology,HeadandNeckSurgerythyroidadenoma /ˈθaɪrɔɪdˌædɪˈnəʊmə/甲状腺腺瘤颈部疾病jugularphlebitis/ˈdʒʌɡjələ(r)fləˈbaɪtɪs/颈静脉炎torticollis/ˌtɔːtɪˈkɒlɪs/斜颈KeyWordsandExpressionspersistent /pəˈsɪstən/ adj. 持续的；反复出现的appetite /ˈæpɪtaɪt/ n. 食欲；胃口swallow /ˈswɒləʊ/ v. 吞下；咽下thermometer /θəˈmɒmɪtə(r)/ n. 体温计；温度计KeyWordsandExpressionsswab /swɒb n.

（医用的）拭子，药签inflame /ɪnˈfleɪm v.

（使）发炎infectious /ɪnˈfekʃəs adj.

传染性的，感染的insomecases 某种情况下antibiotic /ˌæntɪbaɪˈɒtɪk n.

抗生素apartfrom 除了……外；此外；加之hearingloss 听力减退，听力损耗nasalmucus /ˈneɪzlˈmjuːkəs n. 鼻涕；鼻黏液MRI abbr.magneticresonanceimaging磁共振成像 /mæɡˈnetɪkˈrezənənsˈɪmɪdʒɪŋ/KeyWordsandExpressionshorrible /ˈhɒrəbl/ adj.

令人震惊的；恐怖的medication /ˌmedɪˈkeɪʃn/ n. 药；药物surgicaloperation /ˈsɜːdʒɪklˌɒpəˈreɪʃn/ 外科手术inaccordancewith 与……一致，依照specification /ˌspesɪfɪˈkeɪʃn/ n.

明细单；说明书bruise /bruːz/ v.

挫伤；撞伤；擦伤relief /rɪˈliːf/ v. （焦虑、痛苦等的）减轻，消除，缓和slightfever 微热，低烧thick /θɪk/ adj.

浓的；黏稠的speculum /ˈspekjələm/ n.

窥器；扩张器flashlight /ˈflæʃlaɪt/ n.

手电筒，手电occupation /ˌɒkjʊˈpeɪʃn/ n.

工作；职业ModelSentences1.Ihavehadapersistentcoughandsorethroatthesedays.我最近这几天一直咳嗽，而且喉咙痛。2.Yourthroatisseriouslyinflamedandthesurfaceofthemouthandthroatareentirelyred.你的喉咙已经严重发炎了，口腔内壁及咽喉表面均因感染而生红。4.Pleasedonotdrink;eatneitherspicynorsaltyfood.不要饮酒，不要吃辛辣的、咸的食物。3.Ihaveneverbeenallergictoantibiotics.我对任何抗生素都不过敏。ModelSentences5.Doyoubreathewellwhensleeping?你睡觉的时候呼吸是否通畅？6.Surgicaloperationisthemosteffectivewaytocurethedisease.手术是治愈这种病最有效的方法。8.AnX-rayscanofyournoseshouldbedonetoseeifthereisafracture.你需要去做一个X光扫描来看看鼻骨是不是骨折了。7.Takethemedicineinaccordancewiththespecification.按照说明书服用给你开的药。ModelSentences9.Doyousleepwell?Andwhatothersymptomsdoyouhave?你睡得好吗？还有没有其他症状？10.Whatdoesthenasalmucuslooklike?Andhowaboutitscolorandsmell?鼻涕是什么样子的？颜色和气味如何？12.It’sdifficultformetofallasleep,soIdon’thaveenoughhigh-qualitysleep.我很难入睡，所以没有充足的高质量睡眠。11.I’llopenyournasalcavitywithaspeculumandthenuseaflashlighttolookinsideyournose.我要用扩张器打开你的鼻腔，然后用手电筒看看你的鼻子内部。ModelSentences13.Cervicalspondylosisisprobablycausedbythepoorposturewithprolongedsittingandlotsofstress.颈椎病很可能是不良姿势的久坐和巨大压力引起的。14.Doingdailyneckexerciseswillhelpyourecoverfromcervicalspondylosis.每天做颈椎运动有助于你的恢复。课堂小结这小结我们学习了耳鼻咽喉头颈外科医学中的常见病、关键词和表达式和模型句子。希望大家能加深对英语词汇的理解并灵活应用。02医患交流Conversation1AcuteTonsillitis急性扁桃体炎Conversation2NasopharynxCarcinoma鼻咽癌Conversation3NoseBoneFracture鼻骨骨折Conversation4ChronicSinusitis慢性鼻窦炎Conversation5CervicalSpondylosis颈椎病Conversation1AcuteTonsillitis急性扁桃体炎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，医生。医生：早上好，你怎么了？患者：我最近这几天一直咳嗽，而且喉咙痛。医生：嗯，你脸色看起来有点黄。这几天饮食正常吗？患者：不正常，我最近胃口不好。因为吞咽困难，我只能吃一些流质食物，有时候还想吐。医生：明白了。那你从什么时候开始有这个症状的？患者：差不多三天了。Conversation1AcuteTonsillitis急性扁桃体炎D:Putthisthermometerunderyourtongue,please.(afewminuteslater)You’vegotaslightfever.Canyouopenyourmouthwideandletmecheckit?Doyoufeelanypainherenow?P:Yes,ithurtswhenyouhititwiththeswab.What’swrongwithme,doctor?Isitserious?D:Yourthroatisseriouslyinflamedandthesurfaceofthemouthandthroatareentirelyred.Itseemsthatyou’vegotacutetonsillitis.P:It’sinfectious,isn’tit?医生：请把这根体温计含在舌下。（几分钟后）你有点发烧。你能张大嘴巴，让我检查一下吗？现在这里痛吗？患者：嗯，你用棉签按压时痛。医生，我这是怎么了？严不严重呀？医生：你的喉咙已经严重发炎了，口腔内壁及咽喉表面均因感染而生红。看来你这是得了急性扁桃体炎。患者：这种病会传染，是吗？Conversation1AcuteTonsillitis急性扁桃体炎D:Well,yes,insomecases.Butdon’tfeelsoupset.Iwillprescribeyousomemedicine.Andyouwillsoonrecoverfromit.Areyouallergictoanykindofantibiotics?P:Ihaveneverbeenallergictoantibiotics.WhatelsedoIneedtopayattentionto?D:Pleasedonotdrink;eatneitherspicynorsaltyfood.P:Thankyouverymuch,doctor.D:Mypleasure.Seeyou!医生：嗯，是的，某种情况下会。但是不用这么难过，我给你开些药，你很快就会恢复。你对抗生素过敏吗？患者：我对任何抗生素都不过敏。还有什么需要我注意的吗？医生：不要饮酒，不要吃辛辣的、咸的食物。患者：非常感谢，医生。医生：非常荣幸，一会儿见。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：医生，我鼻涕流得厉害。此外，我还头痛，听力也下降了。医生：鼻涕里带血吗？患者：是的，有时候带血。医生：你睡觉的时候呼吸是否通畅？患者：不是很通畅，几乎要喘不过气来了，而且半夜咳嗽得很厉害。医生：这样的症状持续多长时间了？患者：已经超过一年了。医生：你应该先做个血液检测和鼻部核磁共振扫描。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。我很快会拿着检查结果再过来。到时候见。（检查结果出来后）医生：根据检查结果，你得的是鼻咽癌。患者：这太可怕了！我该怎么办？医生：不用担心，我会给你开些药来帮你控制病情。如果病情控制住了，就可以进行手术。手术是治愈这种病最有效的方法。Conversation2NasopharynxCarcinoma鼻咽癌P:Whatarelief!Thankssomuch.D:Areyouallergictoanykindofmedicine?P:No,neverhadbefore.D:OK.Takethemedicineinaccordancewiththespecification.P:Thankssomuch.D:Mypleasure.Hopeyourecoversoon.患者：这下我放心了！太感谢了。医生：你对什么药物过敏吗？患者：没有，之前没有过敏过。医生：好了。按照说明书服用给你开的药。患者：非常感谢。医生：不客气，希望你尽快康复。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，医生。医生：你怎么了？患者：昨天我摔倒了，鼻子磕在了地板上。不幸的是，我的鼻子严重挫伤。太疼了。医生：让我仔细检查一下。患者：就是这儿！哎呦，我的鼻子！医生：你需要去做一个X光扫描来看看鼻骨是不是骨折了。（做完X光后）是的，是骨折。患者：你可以给我开点止疼药缓解一下疼痛吗？医生：你对什么药品过敏吗？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。医生：我推荐你使用这一品牌的快速止痛药。患者：这药真的有效果吗？医生：有效果。给你。上面的说明会告诉你怎么服用，一定得看仔细了。患者：谢谢你的提醒。医生：希望你早日康复。患者：谢谢。医生：不客气。Conversation4ChronicSinusitis慢性鼻窦炎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，医生。医生：你怎么了，年轻人？患者：上个月我得了重感冒。从那以后，我就一直流鼻涕，而且头痛得厉害，白天感觉太疲惫以至于无法专心工作。医生：你睡得好吗？还有没有其他症状？患者：我睡眠质量不好，而且偶尔发低烧。医生：鼻涕是什么样子的？颜色和气味如何？

患者：比较黏稠，颜色和气味也不正常。Conversation4ChronicSinusitis慢性鼻窦炎D:Pleasesitdownandjustrelax.I’llopenyournasalcavitywithaspeculumandthenuseaflashlighttolookinsideyournose.P:OK.(afterfiveminutes)D:Oh,youmaysufferfromchronicsinusitis.HaveyoueverhadaCTscanofyournoseinanyhospital?P:No.D:Hmm,youhavetodoanoseCTscantoconfirmthediagnosisofchronicsinusitis.医生：请坐下，放松。我要用扩张器打开你的鼻腔，然后用手电筒看看你的鼻子内部。患者：好的。（5分钟过后）医生：哦，你可能患有慢性鼻窦炎。你之前在医院做过鼻部CT检查吗？患者：没做过。医生：嗯，你必须做一个鼻部CT扫描来确认慢性鼻窦炎的诊断。Conversation4ChronicSinusitis慢性鼻窦炎P:Noproblem.D:ComebackwithyourexaminationresultsandIwillprescribeyousomemedication.P:Thanksalot.Seeyouthen.D:Seeyou.患者：没问题。医生：带上你的检查结果回来，到时候我会给你配些药。患者：非常感谢您，一会儿见。医生：一会儿见。Conversation5CervicalSpondylosis颈椎病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，医生。这些天我脖子有点痛。医生：你觉得脖子僵硬吗？患者：是的，有点。医生：你是做什么工作的？患者：我是个程序员，周一到周六都需要工作，工作时间特别长。医生：你睡得好吗？患者：我很难入睡，所以没有充足的高质量睡眠。医生：请躺下，放松肌肉，让我检查一下。我按压这里的时候疼吗？患者：是的，很疼。请不要那么用力按这里。Conversation5CervicalSpondylosis颈椎病D:Clearly,youaresufferingfromcervicalspondylosis.P:Oh,what’sthecauseofthiskindofdisease?D:Therearemanyfactorsthatcanleadtothisdisease.Butforyou,theyareprobablythepoorposturewithprolongedsittingandlotsofstress.P:Thencanyouprescribemesomemedicationstoeasemyneckpain?D:Ofcourse.What’smore,doingdailyneckexerciseswillhelpyourecoverfromcervicalspondylosis.P:OK.Thankyouverymuch,doctor.医生：很明显，你得了颈椎病。患者：哦，什么会引起这种病？医生：有很多因素可以引起这种病。但对你来说，可能是不良姿势的久坐和巨大压力引起的。患者：那你能帮我开些药来缓解脖子的痛吗？医生：当然可以。此外，每天做颈椎运动有助于你的恢复。

患者：好的，谢谢医生。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—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门诊病历—急性化脓性扁桃腺炎主诉：吞咽痛伴发热3天。现病史：患者发病以来吞咽疼痛，伴发热、头痛、全身乏力。无张口困难，无寒战、抽搐，无呼吸困难。既往史：平素体健，无药物过敏史，无高血压、糖尿病病史，无心、肺疾病史。体格检查：体温：39℃ 脉搏：80次/分呼吸：18次/分 血压：110/76mmHg口咽部有充血、肿胀，双扁桃体Ⅱ度肿大。OutpatientMedicalRecords—AcutePurulentTonsillitis门诊病历—急性化脓性扁桃腺炎辅助检查：血常规：白细胞（WBC）7.2×109/L，血小板（PLT）48×109/L，淋巴细胞百分比（LYMPH）16.9%。血型：A型初步诊断：急性扁桃体炎处置：1．抗生素药物治疗。

2．增强免疫。医师签名：张××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入院病历（病史采集）—鼻中隔偏曲姓名：任×× 性别：女年龄：29岁 民族：汉职业：工人 婚姻状况：未婚国籍：中国 籍贯：××现住址：×××× 病史陈述者：本人入院日期：2019-09-17 病历记录时间：2019-09-17，17:00主诉：鼻塞，鼻内有脓性分泌物，持续9年。现病史：患者9年前无明显诱因鼻内有脓性分泌物，鼻塞。无发热、头晕和头痛等不适。当地医院诊断为“鼻中隔偏曲”，建议手术，因经济原因选择药物治疗（具体不详）。现患者欲手术，来我院就诊，门诊以“鼻中隔偏曲”收入我科。患病以来，患者精神、体力一般，饮食正常，二便正常。AdmissionMedicalRecords(HistoryCollection)—DeviationofNasalSeptum入院病历（病史采集）—鼻中隔偏曲既往史：平素体健，无药物过敏史，无高血压、糖尿病病史。无心、肺疾病史。个人史：生于原籍，在原籍长大，生活条件一般。无毒品接触史，无吸烟史，无饮酒史。月经史：月经初潮14岁，经期持续4～5天，周期30天，末次月经2019年9月1

日。婚育史：未婚未育。家族史：父母健在，均体健。医师签名：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手术记录—慢性中耳炎姓名：刘××手术日期：2019-08-15，15:26术前诊断：慢性中耳炎，浆液性渗出，腺体增生术中诊断：慢性中耳炎，浆液性渗出，腺体增生手术名称：鼓膜切开置管术（置入暂时性Armstronggrommet鼓膜通气管）+腺体切除术手术医师：王××麻醉方式：局部麻醉手术经过：患者仰卧位，麻醉成功后，在显微镜下清除右侧外耳道。吸除中耳液体。通过切口放入Armstronggrommet并旋转到位。清理另一耳朵，吸除中耳液体。通过切口放入Armstronggrommet并旋转到位。术后两耳均使用抗生素滴耳液。术毕患者安返病房。医师签名：王××上级医师签名：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体格检查—鼻中隔偏曲体温：36.7℃ 脉搏：80次/分呼吸：18次/分 血压：110/76mmHg一般情况：发育正常，营养中等，自动体位。全身皮肤、巩膜无黄染。浅表淋巴结未扪及。头颅大小正常，无畸形及肿块。耳鼻喉：见专科情况。眼睛：眼睑无下垂、内翻，结膜无充血、水肿，双侧瞳孔等大、等圆，对光反射灵敏。颈部：颈软，颈静脉无怒张，甲状腺不肿大，气管居中。胸部：胸廓对称、无畸形。肺：双肺语颤传导正常，无胸膜摩擦音，叩诊呈清音。双肺呼吸音清，未闻及干、湿啰音。PhysicalExamination—DeviationofNasalSeptum体格检查—鼻中隔偏曲心脏：心前区无隆起，心尖搏动位于第五肋间左锁骨中线内0.5

cm处，未触及震颤，心界叩诊不大。心率80次/分。律齐，无杂音。腹部：腹部平坦，无腹壁静脉曲张。未见胃肠型及蠕动波。全腹无压痛及反跳痛。肝、脾肋下未触及，肝区无叩痛，双肾区无叩痛。移动性浊音阴性，肠鸣音正常。四肢：四肢活动自如。神经系统：生理反射正常，无病理反射。肛门及外生殖系统：未查。思想引领“中国耳鼻喉领域第一人”韩德民：诠释一位医者的责任韩德民，中共党员，中国工程院院士，世界华人耳鼻喉头颈外科学理事会理事长，中国医师协会耳鼻喉头颈外科学分会会长，教育部重点实验室主任，首都医科大学耳鼻咽喉科学院院长，中国医疗保健国际交流促进会会长，中国华夏医学科技奖理事会理事长，世界卫生组织防聋合作中心主任，全国防聋治聋技术指导组组长。……详见课本第141页课堂小结这小结我们学习了关于耳鼻咽喉头颈外科如何用英语进行门诊病历、入院病例、手术记录和检查报告的记录。希望大家在实践中能够