關於Present illness的寫法
发布于 2004-11-08 · 浏览 2594 · IP 北京北京
这个帖子发布于 20 年零 182 天前，其中的信息可能已发生改变或有所发展。
病歷研究所III
¤李偉平醫師
現在病史
對大部分的住院醫師而言，要寫一份簡單且合乎文法之Present illness 並不容易。即使是 Mortality and Morbidity Conference 內之Present illness大概只有懂中文的人，甚至可能只有長庚內科的醫師才看得懂。在Written English中的每一句只能有一個動詞。
這樣的基本文法講起來容易，寫起來儘管是醫學院之高材生也可能錯誤百出。有時，你越想表現英文實力，越容易出錯。更有剛在某篇英文雜誌讀到的單字，趁熱寫在Present illness 裏。某位醫師這麼寫：Nowadays fever subsided。用 Nowadays 這樣的 big word！你可以寫 Nowadays young people of the new generation behave so weird that I doubt they are borne by human beings。（感嘆：新一代年青人行為怪異，懷疑他們是否是人生的）。當你要使用一個從沒用過的字，何妨翻翻字典？下面是一個簡單的範例：
DM with cellulites
第一句你可能描述：病人罹患 DM 若干年。
The patient, a 65-year-old female, has had DM for 10 years.
這樣簡單的句子卻常見到許多不恰當的寫法。
This 65-year-old female was a case of DM for 10 years.
This 65-year-old female had DM for 10 years.
這樣寫的確沒有甚麼文法錯誤，但你得補上一句。She still has DM right now. 否則你描述的是「病患在過去曾罹患十年糖尿病」（1977-1987？， 1987-1997？，還是 1991-2001？） 你若寫 She has had DM for 10 years. 則一目瞭然：病患自 1991 年罹患 DM 至今。
也有人這樣寫：
This 65-year-old female is a case of DM for 10 years.
This 65-year-old female has DM for 10 years.
現在式既然是描述 「此時此刻」所發生之事，怎可能「for 10 years」？
接著你可能想敘述病患過去之治療：
She took OHA (Oral Hypoglycemic Agent) for regular control of blood sugar.
She did not receive any treatment before.
She did not receive any treatment until the last two years.
She took OHA in the first eight years and then received insulin treatment during the past two years.
不管你怎麼寫，只要謹守一個原則S+V+O（主詞 + 動詞 + 受詞）就不會出錯。
Cellulitis常有一個先前被忽略的小傷口
According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks before this admission.
She fell and got a scrape wound in the right foot.
She fell on a banana skin.
She fell on the wet floor.
She slipped on the wet floor.
"falling down accident" 就有點像在寫中文
She was hurt by a tiny thorn in the right foot.
She scratched her toes, resulting in a tiny wound in the big toe of the right foot.
She got a cutting wound in the right index finger.
She cut her right index finger.
手被割傷常見到這樣的寫法：
Her right index finger was stabbed by a knife. 儘管文法正確，但小小割傷卻用 stab 這字未免小題大作。
不管你怎麼寫，不要想得太複雜！
接著，你可能描述病患如何處理那小傷口：
She did not pay much attention to the wound until it became red and swollen. 這是大多數病患之通性。
或者：
She did not take care of the wound very well but rather applied to it better iodine solution occasionally. The wound turned red and swollen one week later.
apply to it better iodine solution = apply better iodine solution to it 因"to it"字較"better iodine solution"短，故調至前面。Apply的受詞為 better iodine solution.
apply 為敷藥的動詞。不要寫成 apply to it with better iodine solution.
apply to 向---申請
apply for 申請---
apply to the hospital for a computer 向醫院申請電腦
病人可能因工作而讓足部浸水：
Her feet got wet usually because she worked in the food market.
Her feet got wet usually because she did the washing at home.
整理一下：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet usually because she worked in the food market. The wound turned red and swollen one week later.
你不必老是寫 A small wound was noted in------. Redness and swelling were noted.
接著，紅腫也許只是局限於足部，病患到鄰近醫院打針吃藥。
The lesion was localized in the right foot initially. Therefore, she visited a local hospital, where oral and parenteral antibiotics were administered.
She sought treatment in a local hospital, where oral and parenteral antibiotics were given.
be localized in = be confined to = be limited to
病患也可能敷以黑藥膏皮。
She was suggested to treat the skin lesion by application to it with an unknown salve made from Chinese herbs.
病患因不按時服藥而導致病灶漫延。
Because she did not take medicines regularly, the infection spread rapidly to the right leg.
spread 之過去式亦為spread
黑藥膏皮使得病灶漫延。
The treatment did not work at all, which even made the infection spread to the right leg.
接下來是某一天下午突然發冷接著發熱。
She had a chill suddenly in the afternoon of December 5, followed by high fever.
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet ususally because she worked in the food market. The wound turned red and swollen one week later. The lesion was localized in the right foot initially. Therefore, she sought treatment in a local hospital, where oral and parenteral antibiotics were administered. Because she did not take medicines regularly, the infection spread rapidly to the right leg. She had a chill suddenly in the afternoon of December 5, followed by high fever.
或者：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet ususally because she worked in the food market. The wound turned red and swollen one week later. The lesion was localized in the right foot initially. Therefore, she was suggested to treat the skin lesion by application to it with an unknown salve made from Chinese herbs. The treatment did not work at all, which even made the infection spread to the right leg. She had a chill suddenly in the afternoon of December 5, followed by high fever.
以上每一句皆符合英文造句之基本架構，你不必把句子弄得很長。寫了兩行，不妨檢查一下是否脫離英文造句之基本架構。你若是 intern，合乎文法之寫作，應列為第一要求。等到習慣遵循文法寫作之後才考慮修詞。
接著，病患被送到急診室。lab data 顯示 leukocytosis，診斷十分明確。抽過 Blood cultrue 及給予 oxacillin + gentamicin 之後，病患住進病房。
Then she was sent to our ER. Lab data there showed leukocytosis with 95% of segmental white cells. Thus, two sets of blood culture were done due to the possibility of sepsis. After initial treatment with oxacillin and gentamicin, she was admitted for further care.
住進病房之後，你可能要描述病患之主要症狀及 rule out 病患的fever 是由於其他感染。
On admission, she had fever and revealed an acute ill-looking but without respiratory distress. Her right leg and foot showed severe swelling with erythema and local heat. There were no cough, sorethroat, rhinorrhea, diarrhea, constipation, and dysuria. CXR did not show evidence of lung infection. A figner stick showed blood sugar of 273 mg/dl. The treatment plan will be directed against leg infection and DM.
以上兩段皆用簡單的句子表達，每一句都有主詞與動詞。我們常見 admission note 出現：
1. 太多----were noted. 例如：Fever was noted. Swelling with erythema and local heat were noted in right leg and foot. 這些句子用「主動」表達較好。
2. 一串片語：No cough, no sorethroat, no diarrhea,----------. FS: 273. Cough （-）, sorethroat （-）, diarrhea （-）-------.
最後整理：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet ususally because she worked in the food market. The wound turned red and swollen one week later. The lesion was localized in the right foot initially. Therefore, she was suggested to treat the skin lesion by application to it with an unknown salve made from Chinese herbs. The treatment did not work at all, which even made the infection spread to the right leg. She had a chill suddenly in the afternoon of December 5, followed by high fever. Then she was sent to our ER. Lab data there showed leukocytosis with 95% of segmental white cells. Thus, two sets of blood culture were done due to the possibility of sepsis. After initial treatment with oxacillin and gentamicin, she was admitted for further care.
On admission, she had fever and revealed an acute ill-looking but without respiratory distress. Her right leg and foot showed severe swelling with erythema and local heat. There were no cough, sorethroat, rhinorrhea, diarrhea, constipation, and dysuria. CXR did not show evidence of lung infection. A figner stick showed blood sugar of 273 mg/dl. The treatment plan will be directed against leg infection and DM.
若你翻開中學英語教材，除了醫學名詞外，上面的英語措詞要比那些文章簡單多了。
＊補充說明：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission.
She took OHA for regular control of blood sugar. 為何你會看到某些情況下有人會寫成: She took OHA for the regular control of blood sugar. "regular control" 是一項看不見摸不著的概念，它不像 table, chair, door 具有可以想像到之形狀。就文法規則而言，可數名詞之前必須加冠詞。
He puts a vase on the table （他將花瓶放於桌上）。除非作者想表答某種特殊函意 They were at table when I arrived. （當我到達時，他們正在吃飯）。「at table」 是之抽象意義為「用餐」。「table」 此時不是真正的可數名詞--桌子。
They were at the table playing poker when I arrived （當我到達時，他們正在打牌）。此時 at the table 指的正是「坐在桌前」沒有甚麼抽象意義。「table」 此時是可數名詞。
He worked part-time in college. （他上大學時半工半讀）。「in college」 並不是指 「在某大學內」；「in college」指的是「上大學時那段日子」。
He works as a security guard in the college.（他在大學裡當警衛）。此時的 college 指的正是有校門，有花草樹木及建築物之 college。
如果你不明究理寫成：He works as a security guard in college. 這句話似有點毛病：怎麼上大學又當警衛？
He works part-time in the college. 他可能並不是正在上大學，可能是高中生晚上到大學裡打工。
為何有人會寫 He took OHA for the regular control of blood sugar。（「the regular control」 而非 「regular control」？） regular control 很抽象，就文法規則而言，抽象名詞之前不必加冠詞（舉例而言：Prevention is better than treatment）。Prevention 與 treatment 都是看不見摸不著的抽象概念。抽象名詞若表達某種具體意義之時，則應適時使用冠詞。
He took OHA for the regular control of blood sugar. The blood sugar level was between 150 and 200 mg/dl. 此時的 regular control 不再「抽象」，其具體意義為 「blood sugar 150-200」。
改寫如下：
He took OHA for the regular control of blood sugar, the level of which was between 150 and 200 mg/dl.
She got a tiny wound. 並不是寫作之正式用法，倒像是病人口述。既然前面寫著 According to---. 「She got a tiny wound.」 旨在描述病患口述。正式之寫法如下：
She sustained a tiny wound.
She had a tiny wound.
「got」 是很常用的字，若是講英文有困難，不妨時時想著 「got」
I got a cold.
I got a free lunch.
I got a ticket （罰單）
I just got back from a trip.
I got a mail from Dr. ABC
the big toe 與 the right foot 都必須有冠詞。
描述身體任何一部份時，請不要忘記冠詞。
There is a vegetation in the mitral valve.
There are multiple cavities in the right upper lobe of the lung.
IVP showed a mass in the pelvis of the right kidney.
關於英文病歷「字」的用法
Heart and the heart
若是在寫一般文章時務須注意 heart 這字。
有一天你請某位主任寫推薦函，一般而言都是自己寫了請主任簽名。
Dr. XXX always cared for his patients with heart. 如果寫成
Dr. XXX always cared for his patients with the heart. 那就讓人不知怎樣想了。（是寫推薦函的人英文水平差？還是要照字面去想：用赤裸裸的心臟去照顧病人？）
with heart 即中文 「用心」之意 （取其抽象意義）；with the heart 大概沒人這樣用。 Heart 之前若有冠詞 the 則通常代表具有血肉之 heart。 你若寫成 with his heart也可以，但總覺得有點畫蛇添足。
The city hall is located in the heart of the city.
此時 heart 又作 「城市之核心」 解。heart 在此既非抽象名詞也非具有血肉之 heart。 如果把城市想成人體一般也有一個「地圖心臟」，那麼 in the heart of the city 不宜寫成 in heart of the city.
Swelling or swollew
His leg was swelling.不知有多少住院醫師寫過這樣的句子？筆者若是午夜三點被叫起來接 new patient 也可能迷迷糊糊這樣寫。His leg was swelling. 是一句合乎文法但有悖常理的句子。
「swelling」 是現在分詞，有正在進行之意。His leg was swelling.意思是：他的腿「正在」腫脹。感覺上，病人的腿很少如吹氣球般，一分一秒地在那兒 swelling。
「swollen」 是過去分詞，有已經完成之意。His leg was swollen. 意思是：他的腿「已經」腫起來。我們看到病人的腿腫起來，是已經完成之表徵，而非正在進行之動作。
Swelling balloon 與 swollen balloon 同樣在形容腫脹的氣球
We dilated the narrowed coronary artery with a swelling balloon. 此時用 swollen balloon 就不恰當。已經 swollen balloon 如何做 dilatation？
A swollen balloon was observed in the monitor. It was used to dilate the narrowed coronary artery. Dilatation 大功告成，monitor上顯示著已經腫脹之氣球。
病人的腿變得紅腫，應寫成：His leg became red and swollen.
下面是病歷中常見到之寫法，不能說錯，但總覺不適當。
His leg became redness and swelling （swelling 作名詞）.
Redness and swelling were noted. （His leg showed redness and swelling 比較恰當）
Redness 是 erythema 之通俗用法。
Skin redness，facial redness 即皮膚或面部紅斑（疹），並不是每個美國人都知道 skin rash。你也許說：I will give you a lotion to treat your skin redness. 較說 skin rash 易讓病人明瞭。
Red eye 各種因素引起之結膜充血 （congestion of the conjunctiva）。換個方式寫 Redness of the eye
報紙的廣告：
A new eyedrop to treat red eye
A new eyedrop to treat redness of the eye
要是寫成 congestion of the conjunctiva 大概很少人看得懂。
Red 之動詞為 redden。
Swell 之動名詞為 swelling；redden 之動名詞為 reddening
下面的寫法提供諸位參考：
His leg showed reddening and swelling. 將 reddening （發紅）與 swelling （發腫） 當作（動）名詞。
最後，許多人往往會質疑「這樣寫對嗎」，舉例而言，a victim of peptic ulcer，是否合乎英文習慣？字典例句實在太少了。在這兒提供一個好方法：到 internet 找英文網站，例如，www.yahoo.com 在 search 內鍵入 a victim of peptic ulcer，按 return。你將找到一籮筐例句。
Revised "Present Illness" from a Morbidity and Mortality Conference
＊ 原文：This 24 y/o male patient was a case of chronic paranasal sinusitis. The symptoms included dizziness and facial numbness.
討論此 case 時，病人已死亡。故第一句寫成 This 24-year-old male patient was a case of chronic paranasal sinusitis. 以簡單的過去式表達過去之事。但chronic paranasal sinusitis 不可能吃幾顆藥可以解決。在 chart 上之 present illness 宜寫成：
This 24-year-old male patient is a case of chronic paranasal sinusitis.
This 24-year-old male patient has suffered from chronic paranasal sinusitis since childhood.
原文可以稍作修飾：
This 24-year-old male patient was a case of chronic paranasal sinusitis. The symptoms of the disease included dizziness and facial numbness.
This 24-year-old male patient was a case of chronic paranasal sinusitis, the symptoms of which included dizziness and facial numbness.
＊ 原文：He went to Taipei VGH ENT OPD for help, and operation was arranged.
換個方式寫：
He sought treatment in ENT OPD of Taipei VGH, where operation for the disease was arranged.
＊ 原文：However, before operation, he had intermittent fever since this Jan. associated with sorethroat, cough with yellowish sputum, and hemoptysis, so he was sent to VGH ER.
看得懂，但總覺有點瑕疵，建議寫成：
However, he started an intermittent fever that was associated with sorethroat, cough with yellowish sputum, and hemoptysis from January this year. Thus, he was sent to VGH ER before the scheduled operation.
1. since 常用於現在完成式或過去完成式，過去式不宜使用since。此句若要使用 since， 可以如下寫：
Before the scheduled operation, however, he had had an intermittent fever since January this year, which was associated with sorethroat, cough with yellowish sputum, and hemoptysis. Thus, he was sent to VGH ER.
2. Operation 指的是前述之 operation，因有所指定，故加 the。
3. intermittent fever 之前加冠詞 an 用以表示此種 fever （很特殊） 伴隨 sorethroat, cough with yellowish sputum, and hemoptysis （尤其是 hemoptysis）。
sorethroat, cough, and hemoptysis 是正式之寫法。有些人寫成 sorethroat, cough and hemoptysis。
He went to Taipei VGH, and there operation was arranged. 不宜寫成：
He went to Taipei VGH and there operation was arranged.
＊ 原文：CXR revealed increased opacity with cavity over left perihilar and right middle lobe.
1. Cavity 是可數名詞，若只有一個「空洞」，應寫成 a cavity。若有多個「空洞」，則寫成 cavities。若用 cavitation 則不必使用定冠詞。
2. perihilar 之後應有 region （或 area）。left perihilar region 及 right middle lobe 應有（並共用） 一個定冠詞。
修改如下：
CXR revealed increased opacity with cavitation over the left perihilar region and right middle lobe.
＊ 原文：Under the impression of pneumonia with lung abscess, he was admitted to VGH ward on 2/16 with antibiotics treatment.
1. VGH ward 應有定冠詞。
2. with antibiotics treatment 這樣寫不好
修改如下：
Under the impression of pneumonia with lung abscess, he was admitted to the VGH ward on February 16 and then treated with antibiotics.
＊ 原文：Because of persistent spiking fever under antibiotics therapy, his family asked for AAD and transfer to our hospital on 2/27.
1. under antibiotics therapy 建議改為 despite the therapy of antibiotics
2. ask for 也可用 request
＊ 原文：At our ER, chest CT revealed 2 masses in the right upper lobe and the posterior part of the left upper lobe with some air density.
建議改為：
At our ER, chest CT revealed 2 masses with some air density in the right upper lobe and the posterior part of the left upper lobe.
＊ 原文：Lung abscess was initially impressed, but Wegener's granulomatosis was highly suspected. Transbronchial lung biopsy on 3/6 revealed granulomatous inflammation.
第二句建議改為：
Transbronchial lung biopsy was done on March 6, the pathology of which revealed granulomatous inflammation.
＊ 原文：Anti-TB drugs was given since 3/8. Later skin petechiae have been noted since the beginning of March, followed by hemorrhagic bullae.
1. 第一句 was 應改為 were。since 若作 「自----以來」 之意，前面多為現在完成式或過去完成式。第一句建議改為：
Anti-TB drugs were given from March 8.
Anti-TB medication started from March 8.
Anti-TB drugs had been given since March 8.
2. 討論此病例之時，該病患已死亡（AAD）。第二句用現在完成式是很嚴重之錯誤。應改為：
Skin petechiae had been noted since the beginning of March, which developed hemorrhagic bullae later.
＊ 原文：After skin biopsy, patient requested AAD on 3/10. However, due to the same symptoms as dry cough, sweating and fever, he was admitted again on 3/16.
1. patient 必須加冠詞----the patient
2. due to the same symptoms as dry cough, sweating and fever 是誤用 the same as 這個片語. 舉例而言: The initial symptoms of acute hepatitis may be the same as those of acute URI, for example, dry cough, sweating, and fever. 因此，原句應改為：However, he was admitted again on March 16 due to the same symptoms as before, including dry cough, sweating, and fever.
全文重寫如下：
This 24-year-old male patient was a case of chronic paranasal sinusitis, the symptoms of which included dizziness and facial numbness. He sought treatment in ENT OPD of Taipei VGH, where operation for the disease was arranged. However, he started an intermittent fever that was associated with sorethroat, cough with yellowish sputum, and hemoptysis from January this year. Thus, he was sent to VGH ER before the scheduled operation. CXR revealed increased opacity with cavitation over the left perihilar region and right middle lobe. Under the impression of pneumonia with lung abscess, he was admitted to the VGH ward on February 16 and then treated with antibiotics. Because of persistent spiking fever under antibiotics therapy, his family asked for AAD and transfer to our hospital on February 27. At our ER, chest CT revealed 2 masses with some air density in the right upper lobe and the posterior part of the left upper lobe. Transbronchial lung biopsy was done on March 6, the pathology of which revealed granulomatous inflammation. Anti-TB medication started from March 8. Skin petechiae had been noted since the beginning of March, which developed hemorrhagic bullae later. After skin biopsy, the patient requested AAD on March 10. However, he was admitted again on March 16 due to the same symptoms as before, including dry cough, sweating, and fever.
¤李偉平醫師
現在病史
對大部分的住院醫師而言，要寫一份簡單且合乎文法之Present illness 並不容易。即使是 Mortality and Morbidity Conference 內之Present illness大概只有懂中文的人，甚至可能只有長庚內科的醫師才看得懂。在Written English中的每一句只能有一個動詞。
這樣的基本文法講起來容易，寫起來儘管是醫學院之高材生也可能錯誤百出。有時，你越想表現英文實力，越容易出錯。更有剛在某篇英文雜誌讀到的單字，趁熱寫在Present illness 裏。某位醫師這麼寫：Nowadays fever subsided。用 Nowadays 這樣的 big word！你可以寫 Nowadays young people of the new generation behave so weird that I doubt they are borne by human beings。（感嘆：新一代年青人行為怪異，懷疑他們是否是人生的）。當你要使用一個從沒用過的字，何妨翻翻字典？下面是一個簡單的範例：
DM with cellulites
第一句你可能描述：病人罹患 DM 若干年。
The patient, a 65-year-old female, has had DM for 10 years.
這樣簡單的句子卻常見到許多不恰當的寫法。
This 65-year-old female was a case of DM for 10 years.
This 65-year-old female had DM for 10 years.
這樣寫的確沒有甚麼文法錯誤，但你得補上一句。She still has DM right now. 否則你描述的是「病患在過去曾罹患十年糖尿病」（1977-1987？， 1987-1997？，還是 1991-2001？） 你若寫 She has had DM for 10 years. 則一目瞭然：病患自 1991 年罹患 DM 至今。
也有人這樣寫：
This 65-year-old female is a case of DM for 10 years.
This 65-year-old female has DM for 10 years.
現在式既然是描述 「此時此刻」所發生之事，怎可能「for 10 years」？
接著你可能想敘述病患過去之治療：
She took OHA (Oral Hypoglycemic Agent) for regular control of blood sugar.
She did not receive any treatment before.
She did not receive any treatment until the last two years.
She took OHA in the first eight years and then received insulin treatment during the past two years.
不管你怎麼寫，只要謹守一個原則S+V+O（主詞 + 動詞 + 受詞）就不會出錯。
Cellulitis常有一個先前被忽略的小傷口
According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks before this admission.
She fell and got a scrape wound in the right foot.
She fell on a banana skin.
She fell on the wet floor.
She slipped on the wet floor.
"falling down accident" 就有點像在寫中文
She was hurt by a tiny thorn in the right foot.
She scratched her toes, resulting in a tiny wound in the big toe of the right foot.
She got a cutting wound in the right index finger.
She cut her right index finger.
手被割傷常見到這樣的寫法：
Her right index finger was stabbed by a knife. 儘管文法正確，但小小割傷卻用 stab 這字未免小題大作。
不管你怎麼寫，不要想得太複雜！
接著，你可能描述病患如何處理那小傷口：
She did not pay much attention to the wound until it became red and swollen. 這是大多數病患之通性。
或者：
She did not take care of the wound very well but rather applied to it better iodine solution occasionally. The wound turned red and swollen one week later.
apply to it better iodine solution = apply better iodine solution to it 因"to it"字較"better iodine solution"短，故調至前面。Apply的受詞為 better iodine solution.
apply 為敷藥的動詞。不要寫成 apply to it with better iodine solution.
apply to 向---申請
apply for 申請---
apply to the hospital for a computer 向醫院申請電腦
病人可能因工作而讓足部浸水：
Her feet got wet usually because she worked in the food market.
Her feet got wet usually because she did the washing at home.
整理一下：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet usually because she worked in the food market. The wound turned red and swollen one week later.
你不必老是寫 A small wound was noted in------. Redness and swelling were noted.
接著，紅腫也許只是局限於足部，病患到鄰近醫院打針吃藥。
The lesion was localized in the right foot initially. Therefore, she visited a local hospital, where oral and parenteral antibiotics were administered.
She sought treatment in a local hospital, where oral and parenteral antibiotics were given.
be localized in = be confined to = be limited to
病患也可能敷以黑藥膏皮。
She was suggested to treat the skin lesion by application to it with an unknown salve made from Chinese herbs.
病患因不按時服藥而導致病灶漫延。
Because she did not take medicines regularly, the infection spread rapidly to the right leg.
spread 之過去式亦為spread
黑藥膏皮使得病灶漫延。
The treatment did not work at all, which even made the infection spread to the right leg.
接下來是某一天下午突然發冷接著發熱。
She had a chill suddenly in the afternoon of December 5, followed by high fever.
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet ususally because she worked in the food market. The wound turned red and swollen one week later. The lesion was localized in the right foot initially. Therefore, she sought treatment in a local hospital, where oral and parenteral antibiotics were administered. Because she did not take medicines regularly, the infection spread rapidly to the right leg. She had a chill suddenly in the afternoon of December 5, followed by high fever.
或者：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet ususally because she worked in the food market. The wound turned red and swollen one week later. The lesion was localized in the right foot initially. Therefore, she was suggested to treat the skin lesion by application to it with an unknown salve made from Chinese herbs. The treatment did not work at all, which even made the infection spread to the right leg. She had a chill suddenly in the afternoon of December 5, followed by high fever.
以上每一句皆符合英文造句之基本架構，你不必把句子弄得很長。寫了兩行，不妨檢查一下是否脫離英文造句之基本架構。你若是 intern，合乎文法之寫作，應列為第一要求。等到習慣遵循文法寫作之後才考慮修詞。
接著，病患被送到急診室。lab data 顯示 leukocytosis，診斷十分明確。抽過 Blood cultrue 及給予 oxacillin + gentamicin 之後，病患住進病房。
Then she was sent to our ER. Lab data there showed leukocytosis with 95% of segmental white cells. Thus, two sets of blood culture were done due to the possibility of sepsis. After initial treatment with oxacillin and gentamicin, she was admitted for further care.
住進病房之後，你可能要描述病患之主要症狀及 rule out 病患的fever 是由於其他感染。
On admission, she had fever and revealed an acute ill-looking but without respiratory distress. Her right leg and foot showed severe swelling with erythema and local heat. There were no cough, sorethroat, rhinorrhea, diarrhea, constipation, and dysuria. CXR did not show evidence of lung infection. A figner stick showed blood sugar of 273 mg/dl. The treatment plan will be directed against leg infection and DM.
以上兩段皆用簡單的句子表達，每一句都有主詞與動詞。我們常見 admission note 出現：
1. 太多----were noted. 例如：Fever was noted. Swelling with erythema and local heat were noted in right leg and foot. 這些句子用「主動」表達較好。
2. 一串片語：No cough, no sorethroat, no diarrhea,----------. FS: 273. Cough （-）, sorethroat （-）, diarrhea （-）-------.
最後整理：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission. She did not take care of the wound very well but rather applied to it better iodine solution occasionally. Furthermore, her feet got wet ususally because she worked in the food market. The wound turned red and swollen one week later. The lesion was localized in the right foot initially. Therefore, she was suggested to treat the skin lesion by application to it with an unknown salve made from Chinese herbs. The treatment did not work at all, which even made the infection spread to the right leg. She had a chill suddenly in the afternoon of December 5, followed by high fever. Then she was sent to our ER. Lab data there showed leukocytosis with 95% of segmental white cells. Thus, two sets of blood culture were done due to the possibility of sepsis. After initial treatment with oxacillin and gentamicin, she was admitted for further care.
On admission, she had fever and revealed an acute ill-looking but without respiratory distress. Her right leg and foot showed severe swelling with erythema and local heat. There were no cough, sorethroat, rhinorrhea, diarrhea, constipation, and dysuria. CXR did not show evidence of lung infection. A figner stick showed blood sugar of 273 mg/dl. The treatment plan will be directed against leg infection and DM.
若你翻開中學英語教材，除了醫學名詞外，上面的英語措詞要比那些文章簡單多了。
＊補充說明：
The patient, a 65-year-old female, has had DM for five years. She took OHA for regular control of blood sugar. According to the statement of the patient herself, she got a tiny wound in the big toe of the right foot two weeks prior to this admission.
She took OHA for regular control of blood sugar. 為何你會看到某些情況下有人會寫成: She took OHA for the regular control of blood sugar. "regular control" 是一項看不見摸不著的概念，它不像 table, chair, door 具有可以想像到之形狀。就文法規則而言，可數名詞之前必須加冠詞。
He puts a vase on the table （他將花瓶放於桌上）。除非作者想表答某種特殊函意 They were at table when I arrived. （當我到達時，他們正在吃飯）。「at table」 是之抽象意義為「用餐」。「table」 此時不是真正的可數名詞--桌子。
They were at the table playing poker when I arrived （當我到達時，他們正在打牌）。此時 at the table 指的正是「坐在桌前」沒有甚麼抽象意義。「table」 此時是可數名詞。
He worked part-time in college. （他上大學時半工半讀）。「in college」 並不是指 「在某大學內」；「in college」指的是「上大學時那段日子」。
He works as a security guard in the college.（他在大學裡當警衛）。此時的 college 指的正是有校門，有花草樹木及建築物之 college。
如果你不明究理寫成：He works as a security guard in college. 這句話似有點毛病：怎麼上大學又當警衛？
He works part-time in the college. 他可能並不是正在上大學，可能是高中生晚上到大學裡打工。
為何有人會寫 He took OHA for the regular control of blood sugar。（「the regular control」 而非 「regular control」？） regular control 很抽象，就文法規則而言，抽象名詞之前不必加冠詞（舉例而言：Prevention is better than treatment）。Prevention 與 treatment 都是看不見摸不著的抽象概念。抽象名詞若表達某種具體意義之時，則應適時使用冠詞。
He took OHA for the regular control of blood sugar. The blood sugar level was between 150 and 200 mg/dl. 此時的 regular control 不再「抽象」，其具體意義為 「blood sugar 150-200」。
改寫如下：
He took OHA for the regular control of blood sugar, the level of which was between 150 and 200 mg/dl.
She got a tiny wound. 並不是寫作之正式用法，倒像是病人口述。既然前面寫著 According to---. 「She got a tiny wound.」 旨在描述病患口述。正式之寫法如下：
She sustained a tiny wound.
She had a tiny wound.
「got」 是很常用的字，若是講英文有困難，不妨時時想著 「got」
I got a cold.
I got a free lunch.
I got a ticket （罰單）
I just got back from a trip.
I got a mail from Dr. ABC
the big toe 與 the right foot 都必須有冠詞。
描述身體任何一部份時，請不要忘記冠詞。
There is a vegetation in the mitral valve.
There are multiple cavities in the right upper lobe of the lung.
IVP showed a mass in the pelvis of the right kidney.
關於英文病歷「字」的用法
Heart and the heart
若是在寫一般文章時務須注意 heart 這字。
有一天你請某位主任寫推薦函，一般而言都是自己寫了請主任簽名。
Dr. XXX always cared for his patients with heart. 如果寫成
Dr. XXX always cared for his patients with the heart. 那就讓人不知怎樣想了。（是寫推薦函的人英文水平差？還是要照字面去想：用赤裸裸的心臟去照顧病人？）
with heart 即中文 「用心」之意 （取其抽象意義）；with the heart 大概沒人這樣用。 Heart 之前若有冠詞 the 則通常代表具有血肉之 heart。 你若寫成 with his heart也可以，但總覺得有點畫蛇添足。
The city hall is located in the heart of the city.
此時 heart 又作 「城市之核心」 解。heart 在此既非抽象名詞也非具有血肉之 heart。 如果把城市想成人體一般也有一個「地圖心臟」，那麼 in the heart of the city 不宜寫成 in heart of the city.
Swelling or swollew
His leg was swelling.不知有多少住院醫師寫過這樣的句子？筆者若是午夜三點被叫起來接 new patient 也可能迷迷糊糊這樣寫。His leg was swelling. 是一句合乎文法但有悖常理的句子。
「swelling」 是現在分詞，有正在進行之意。His leg was swelling.意思是：他的腿「正在」腫脹。感覺上，病人的腿很少如吹氣球般，一分一秒地在那兒 swelling。
「swollen」 是過去分詞，有已經完成之意。His leg was swollen. 意思是：他的腿「已經」腫起來。我們看到病人的腿腫起來，是已經完成之表徵，而非正在進行之動作。
Swelling balloon 與 swollen balloon 同樣在形容腫脹的氣球
We dilated the narrowed coronary artery with a swelling balloon. 此時用 swollen balloon 就不恰當。已經 swollen balloon 如何做 dilatation？
A swollen balloon was observed in the monitor. It was used to dilate the narrowed coronary artery. Dilatation 大功告成，monitor上顯示著已經腫脹之氣球。
病人的腿變得紅腫，應寫成：His leg became red and swollen.
下面是病歷中常見到之寫法，不能說錯，但總覺不適當。
His leg became redness and swelling （swelling 作名詞）.
Redness and swelling were noted. （His leg showed redness and swelling 比較恰當）
Redness 是 erythema 之通俗用法。
Skin redness，facial redness 即皮膚或面部紅斑（疹），並不是每個美國人都知道 skin rash。你也許說：I will give you a lotion to treat your skin redness. 較說 skin rash 易讓病人明瞭。
Red eye 各種因素引起之結膜充血 （congestion of the conjunctiva）。換個方式寫 Redness of the eye
報紙的廣告：
A new eyedrop to treat red eye
A new eyedrop to treat redness of the eye
要是寫成 congestion of the conjunctiva 大概很少人看得懂。
Red 之動詞為 redden。
Swell 之動名詞為 swelling；redden 之動名詞為 reddening
下面的寫法提供諸位參考：
His leg showed reddening and swelling. 將 reddening （發紅）與 swelling （發腫） 當作（動）名詞。
最後，許多人往往會質疑「這樣寫對嗎」，舉例而言，a victim of peptic ulcer，是否合乎英文習慣？字典例句實在太少了。在這兒提供一個好方法：到 internet 找英文網站，例如，www.yahoo.com 在 search 內鍵入 a victim of peptic ulcer，按 return。你將找到一籮筐例句。
Revised "Present Illness" from a Morbidity and Mortality Conference
＊ 原文：This 24 y/o male patient was a case of chronic paranasal sinusitis. The symptoms included dizziness and facial numbness.
討論此 case 時，病人已死亡。故第一句寫成 This 24-year-old male patient was a case of chronic paranasal sinusitis. 以簡單的過去式表達過去之事。但chronic paranasal sinusitis 不可能吃幾顆藥可以解決。在 chart 上之 present illness 宜寫成：
This 24-year-old male patient is a case of chronic paranasal sinusitis.
This 24-year-old male patient has suffered from chronic paranasal sinusitis since childhood.
原文可以稍作修飾：
This 24-year-old male patient was a case of chronic paranasal sinusitis. The symptoms of the disease included dizziness and facial numbness.
This 24-year-old male patient was a case of chronic paranasal sinusitis, the symptoms of which included dizziness and facial numbness.
＊ 原文：He went to Taipei VGH ENT OPD for help, and operation was arranged.
換個方式寫：
He sought treatment in ENT OPD of Taipei VGH, where operation for the disease was arranged.
＊ 原文：However, before operation, he had intermittent fever since this Jan. associated with sorethroat, cough with yellowish sputum, and hemoptysis, so he was sent to VGH ER.
看得懂，但總覺有點瑕疵，建議寫成：
However, he started an intermittent fever that was associated with sorethroat, cough with yellowish sputum, and hemoptysis from January this year. Thus, he was sent to VGH ER before the scheduled operation.
1. since 常用於現在完成式或過去完成式，過去式不宜使用since。此句若要使用 since， 可以如下寫：
Before the scheduled operation, however, he had had an intermittent fever since January this year, which was associated with sorethroat, cough with yellowish sputum, and hemoptysis. Thus, he was sent to VGH ER.
2. Operation 指的是前述之 operation，因有所指定，故加 the。
3. intermittent fever 之前加冠詞 an 用以表示此種 fever （很特殊） 伴隨 sorethroat, cough with yellowish sputum, and hemoptysis （尤其是 hemoptysis）。
sorethroat, cough, and hemoptysis 是正式之寫法。有些人寫成 sorethroat, cough and hemoptysis。
He went to Taipei VGH, and there operation was arranged. 不宜寫成：
He went to Taipei VGH and there operation was arranged.
＊ 原文：CXR revealed increased opacity with cavity over left perihilar and right middle lobe.
1. Cavity 是可數名詞，若只有一個「空洞」，應寫成 a cavity。若有多個「空洞」，則寫成 cavities。若用 cavitation 則不必使用定冠詞。
2. perihilar 之後應有 region （或 area）。left perihilar region 及 right middle lobe 應有（並共用） 一個定冠詞。
修改如下：
CXR revealed increased opacity with cavitation over the left perihilar region and right middle lobe.
＊ 原文：Under the impression of pneumonia with lung abscess, he was admitted to VGH ward on 2/16 with antibiotics treatment.
1. VGH ward 應有定冠詞。
2. with antibiotics treatment 這樣寫不好
修改如下：
Under the impression of pneumonia with lung abscess, he was admitted to the VGH ward on February 16 and then treated with antibiotics.
＊ 原文：Because of persistent spiking fever under antibiotics therapy, his family asked for AAD and transfer to our hospital on 2/27.
1. under antibiotics therapy 建議改為 despite the therapy of antibiotics
2. ask for 也可用 request
＊ 原文：At our ER, chest CT revealed 2 masses in the right upper lobe and the posterior part of the left upper lobe with some air density.
建議改為：
At our ER, chest CT revealed 2 masses with some air density in the right upper lobe and the posterior part of the left upper lobe.
＊ 原文：Lung abscess was initially impressed, but Wegener's granulomatosis was highly suspected. Transbronchial lung biopsy on 3/6 revealed granulomatous inflammation.
第二句建議改為：
Transbronchial lung biopsy was done on March 6, the pathology of which revealed granulomatous inflammation.
＊ 原文：Anti-TB drugs was given since 3/8. Later skin petechiae have been noted since the beginning of March, followed by hemorrhagic bullae.
1. 第一句 was 應改為 were。since 若作 「自----以來」 之意，前面多為現在完成式或過去完成式。第一句建議改為：
Anti-TB drugs were given from March 8.
Anti-TB medication started from March 8.
Anti-TB drugs had been given since March 8.
2. 討論此病例之時，該病患已死亡（AAD）。第二句用現在完成式是很嚴重之錯誤。應改為：
Skin petechiae had been noted since the beginning of March, which developed hemorrhagic bullae later.
＊ 原文：After skin biopsy, patient requested AAD on 3/10. However, due to the same symptoms as dry cough, sweating and fever, he was admitted again on 3/16.
1. patient 必須加冠詞----the patient
2. due to the same symptoms as dry cough, sweating and fever 是誤用 the same as 這個片語. 舉例而言: The initial symptoms of acute hepatitis may be the same as those of acute URI, for example, dry cough, sweating, and fever. 因此，原句應改為：However, he was admitted again on March 16 due to the same symptoms as before, including dry cough, sweating, and fever.
全文重寫如下：
This 24-year-old male patient was a case of chronic paranasal sinusitis, the symptoms of which included dizziness and facial numbness. He sought treatment in ENT OPD of Taipei VGH, where operation for the disease was arranged. However, he started an intermittent fever that was associated with sorethroat, cough with yellowish sputum, and hemoptysis from January this year. Thus, he was sent to VGH ER before the scheduled operation. CXR revealed increased opacity with cavitation over the left perihilar region and right middle lobe. Under the impression of pneumonia with lung abscess, he was admitted to the VGH ward on February 16 and then treated with antibiotics. Because of persistent spiking fever under antibiotics therapy, his family asked for AAD and transfer to our hospital on February 27. At our ER, chest CT revealed 2 masses with some air density in the right upper lobe and the posterior part of the left upper lobe. Transbronchial lung biopsy was done on March 6, the pathology of which revealed granulomatous inflammation. Anti-TB medication started from March 8. Skin petechiae had been noted since the beginning of March, which developed hemorrhagic bullae later. After skin biopsy, the patient requested AAD on March 10. However, he was admitted again on March 16 due to the same symptoms as before, including dry cough, sweating, and fever.
最后编辑于 2022-10-09 · 浏览 2594
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