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Nursing rounds of cerebral hemorrhageXu guiying：Department of NeurologyCerebral hemorrhageRefers to the primary substance of non-traumatic brain hemorrhage，which accounts for 20% to 30% in acute cerebrovascular diseasecerebral vascular disease.脑出血是指原发性脑实质出血占全部脑卒中的20%~30%Etiological factor（1）Hypertension with atherosclerosis (most common)。
（2）Intracranial aneurysms (mainly congenital aneurysm)。
（3）Cerebral arteriovenous malformations（4）Other: moyamoya disease, blood disease.病因（1）高血压并发细小动脉硬化（最常见）。
（2）颅内动脉瘤（主要是先天性动脉瘤）。
（3）脑动静脉畸形（4）其他：脑动脉炎，脑底异常血管网症、血液病。
PathogenesisBasis of disease: hypertension and cerebrovascular diseaseAdditional factors:force and emotional changes发病机制基础疾病：高血压，脑血管疾病其他因素：用力，情绪改变Clinical manifestations1.it Often occurs in the hypertensive patients who are over 50 years old2.Prodromal symptoms often do not have a feeling, a small number of dizziness, headache, numbness and slurred speech, and many more in the emotional stress, excitement, bowel movements, hard, and when the incidence of severe climate change.2.临床表现1。
最全的医学英语之NO.11、抗生素医嘱[Antibiotic order]Prophylaxis 预防性用药Duration of oder 用药时间Procedure 操作，手术Empiric theraphy 经验性治疗Suspected site and organism 怀疑感染的部位和致病菌Cultures ordered 做培养Documented infection 明确感染Site and organism 部位和致病菌Explanation required 解释理由Antibiotic allergies 何种抗生素过敏No known allergy 无已知的过敏Drug+dose+Route+frequency药名+剂量+途径+次数2、医嘱首页[Admission / transfer] Admit / transfer to 收入或转入Resident 住院医师Attending 主治医师Condition 病情Diagnosis 诊断Diet 饮食Acitivity 活动Vital signs 生命体征I / O 记进出量Allergies 过敏3、住院病历[case history]Identification 病人一般情况Name 姓名Sex 性别Age 年龄Marriage 婚姻Person to notify and phone No. 联系人及电话Race 民族I.D.No. 身份证Admission date 入院日期Source of history 病史提供者Reliability of history 可靠程度Medical record No 病历号Business phone No 工作单位电话Home address and phone No 家庭住地及电话Chief complaint 主诉History of present illness 现病史Past History 过去史Surgical 外科Medical 内科Medications 用药Allergies 过敏史Social History 社会史Habits 个人习惯Smoking 吸烟Family History 家族史Ob/Gyn History 婚姻/生育史Alcohol use 喝酒Review of Systems 系统回顾General 概况Eyes,Ears,Nose and throat 五官Pulmonary 呼吸Cardiovascular 心血管GI 消化GU 生殖、泌尿系统Musculoskeletal 肌肉骨骼Neurology 神经系统Endocrinology 内分泌系统Lymphatic/Hematologic 淋巴系统/血液系统Physical Exam 体检Vital Signs 生命体征P 脉博Bp 血压R 呼吸T 温度Height 身高Weight 体重General 概况HEENT 五官Neck 颈部Back/Chest 背部/胸部Breast 乳房Heart 心脏Heart rate 心率Heart rhythm 心律Heart Border 心界Murmur 杂音Abdomen 腹部Liver 肝Spleen 脾Rectal 直肠Genitalia 生殖系统Extremities 四肢Neurology 神经系统cranial nerves 颅神经sensation 感觉Motor 运动*Special P.E. on diseased organ system[专科情况]*Radiographic Findings[放射]*Laboratory Findings[化验]*Assessment[初步诊断与诊断依据]*Summary[病史小结]*Treatment Plan[治疗计划]4、输血申请单[Blood bank requisition form](1)reason for infusion[输血原因]▲红细胞[packed red cells, washed RBCs]: *Hb<8.5 [血色素<8.5]*>20% blood volume lost [>20%血容量丢失]*cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素<8]*chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者]▲全血[whole blood]:massive on-going blood loss[大量出血]▲血小板[platelets]:*massive blood transfusion >10 units[输血10单位以上者]*platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活动性出血或手术者]*Cardio-pulmonary bypass uithpl<100×103/μl wit h octive bleeding[心肺分流术伴血小板<10万，活动性出血者]*Platelet count <20×103/μl[血板<2万]▲新鲜冰冻血浆[fresh frozen plasma]:*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的出血或手术病人]*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手术者]*blood transfusion >15units[输血>15个单位] *warfarin or antifibrinolytic therapy with bleeding[华法令或溶栓治疗后出血]*DIC[血管内弥漫性凝血]*Antithrombin III dficiency[凝血酶III 缺乏](2)输血要求[request for blood components]*patient blood group[血型]*Has the patient had transfusion or pregnancy in the past 3 months? [近3个月，病人是否输过血或怀孕过？]*Type and crossmatch[血型和血交叉]*Units or ml[单位或毫升]5、出院小结[discharge summary]Patient Name[病人姓名]Medical Record No.[病历号]Attending Physician[主治医生]Date of Admission[入院日期]Date of Discharge[出院日期]Pirncipal Diagnosis[主要诊断]Secondary Diagnosis[次要诊断]Complications[并发症]Operation[手术名称]Reason for Admission[入院理由]Physical Findings[阳性体征]Lab/X-ray Findings[化验及放射报告]Hospital Course[住院诊治经过]Condition[出院状况]Disposition[出院去向]Medications[出院用药]Prognosis[预后]Special Instruction to the Patient(diet, physical activity)[出院指导（饮食，活动量）]Follow-up Care[随随访]6、住院/出院病历首页[Admission/discharge record]Patient name[病人姓名]race[种族]address[地址]religion[宗教]medical service[科别]admit (discharge) date[入院（出院）日期]Length of stay [住院天数]guarantor name [担保人姓名]next of kin or person to notify[需通知的亲属姓名]relation to patient[与病人关系]previous admit date[上次住院日期]admitting physician [入院医生]attending phgsician[主治医生]admitting diagnosis[入院诊断]final (principal) diagnosis[最终（主要）诊断]secondary diagnosis[次要诊断]adverse reactions (complications)[副作用（合并症）] incision type[切口类型]healing course[愈合等级]operative (non-operative) procedures[手术（非手术）操作]nosocomial infection[院内感染]consutants[会诊]Critical-No. of times[抢救次数]recovered-No. of times[成功次数]Diagnosis qualitative analysis[诊断质量]OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率]Clinical and pathological Dx concur[临床与病理诊断符合率]Pre- and post-operative Dx concur [术前术后诊断符合率]Dx determined with in 24 hours (3 days) after admission[入院后24小时（3天）内确诊]Discharge status[出院状况]recovered[治愈]improved[好转]not improved[未愈]died [死亡]Dispositon[去向]home[家]against medical ad[自动出院]autosy[尸检]transferred to[转院到。
Face and neck scar after implanting the expanders面颈部瘢痕，扩张器植入术后Face scar excision, removed the expanders and replaced the scar with expanded flap 面部瘢痕切除，扩张器去除，扩张皮瓣转移Rectangular mandible and hypertrophy of masseter方形下颌骨，咬肌肥大Out layer of mandible osteotomy and part of masseter excision下颌骨外板截骨，部分咬肌切除Saddle nose and wry nose after trauma鞍鼻，歪鼻外伤后Saddle nose and wry nose correction鞍鼻歪鼻矫正Rectangular mandible and hypertrophy of masseter方形下颌骨，咬肌肥大Mandible angle osteotomy, part of masseter excision and buccal pad removing下颌角截骨，部分咬肌切除，颊脂垫去除Secondary deformity after lip-cleft correction唇裂矫正术后继发畸形Lip deformity correction唇畸形矫正Wry neck斜颈Wry neck correction斜颈矫正Low nose, hypertrophy of nose tip and microgenia低鼻，鼻尖肥大，小颏Nose augmentation with silicon implanter, nose tip reduction, mentum horizontal osteotomy and move forward硅胶假体植入隆鼻，鼻尖缩小，颏部水平截骨前移Aging face and baggy eyelids面部老化，睑袋Face and neck lifting and baggy eyelids excision面颈部提升，睑袋切除Left face and eye depression after tumor excision左面部眼部凹陷，肿瘤切除术后Left face and eye depression filling with autogenous cranial bone and medpor and skin graft from abdomen to release the contraction of the left lower eyelid自体颅骨（外板）切取、medpor，左面部眼部凹陷填充，腹部皮肤移植，左侧下睑挛缩松解Protrusion of zygoma, ectropion of lower eyelids,颧骨突出，下睑外翻Zygoma osteotomy and down fracture and eyelids ectropian correction and temple lifting颧骨截骨下降，眼睑外翻矫正，颞部提升Bilateral secondary deformity after lip cleft correction and alveolar crest cleft唇裂矫正术后双侧继发畸形，牙槽嵴裂Lip and nose deformity correction, alveolar crest cleft repairing with autogenous iliac 唇鼻畸形矫正，取自体髂骨，牙槽嵴裂修复Aging face and prominent mandibular angle(PMA)面部老化，下颌角肥大Frontal and temple lifting and mandible angle grinding额颞部提升，下颌角打磨Face and body scar after burn, ectropion of lower eyelids烧伤后面部躯干瘢痕，下眼睑外翻Eyelids ectropion correction with skin graft from right arm and implanted 2 expanders in the abdomen右上肢皮肤移植，眼睑外翻矫正，腹部扩张器植入Baggy eyelid, low nose, and hypertrophy of nasal tip睑袋，低鼻，鼻尖肥大Baggy eyelid excision, nose augmentation and nasal tip reduction睑袋切除，隆鼻，鼻尖缩小Fat and clumsy of the left ankle flapLeft ankle flap trimmingFace scar and absence of eyebrow面疤，眉毛缺失Eyebrow implanting眉毛种植Lip and nose deformity after lip-cleft correction唇裂矫正术后唇鼻畸形Lip and nose deformity correction唇鼻畸形矫正The first and second branchial arch syndrome第一、二鳃弓综合征Macrostomia correction and skin tag before the left ear excision, facial cleft,nose tip plasty and lengthen the nasal columella大口畸形矫正，左耳前皮赘切除，面裂鼻尖成形，鼻小住延长Right arm granulation wound右上肢肉芽创面Skin graft from the right leg右腿皮肤移植Body scar after burn烧伤后全身瘢痕Implanted 2 expanders in the back and 2 expanders in the leg,abdomen scar dermabrasion背部腿部扩脏器植入，腹部瘢痕磨削术Face and neck scar after burn烧伤后面颈部瘢痕Frontal skin grinding and implanted 2 expanders额部皮肤打磨，扩张器植入Popliteal fossa scar after burn and cicatricial contracture烧伤后腘窝瘢痕，瘢痕挛缩Liposuction, autogenous fat particle injection transplantation吸脂术，字体脂肪颗粒注射移植Rhytidoplasty除皱术Multiple craniofacial fractures after trauma外伤后多发性颅面骨折Frontal glabella depression filling with autogenous cranial bone , internal fixation by Ti plate and Ti screw, nasal bone fracture reduction, wry nose deformity correction, Internal fixation of left zygoma and maxilla by Ti plate and Ti screw自体颅骨外板切取，额部眉间凹陷填充，钛板钛钉内固定，鼻骨骨折复位，歪鼻矫正，左颧骨上颌骨骨折钛板钛钉内固定Osteotomy and inward shift of right zygoma, internal fixation by Ti plate and Ti screw, grinding of left zygoma, nose augmentation with silicon implanter, right frontal and temple lifting右侧颧骨截骨内收，钛板钛钉内固定，左侧颧骨打磨，硅胶假体植入隆鼻，右侧额颞部提升The pantient’s name is ,male(female) or year’s old boy(girl). The diagnosis is .We performed the operation of last Monday(yesterday or 3 days ago). We gave the patient antibiotic and hemostatic(or we tried to improve the microcirculation of flap) after operation. The drainage tube was removed in the second day post operation. We changed the dress in the second day post operation. Today is the fourth day after operation, the condition of the patient is good, temperature is normal.。
PBL教学查房法第一篇：PBL教学查房法problem-based learning简称PBL 以问题为导向的教学查房方法PBL护理查房是以问题为基础的护理查房，主要通过讨论对疑难、危重病例，新业务、新技术等中存在的问题进行有准备、有目的、有针对性地讨论、分析，最终找出解决问题的查房过程。
该模式打破了传统的以听为主，只回报而缺少分析的查房模式，能够针对病人的病情或存在的问题进行深入深讨，不断改进护理措施。
PBL教学查房目标通过开展PBL护理查房，解决病人存在的护理问题。
学习必要的知识学会正确的临床思维和推理方法培养解决问题的能力培养自学能力。
第二篇：PBL教学查房2014年7月疟疾PBL教学查房——疟疾护士长陈连方老师主持：近期，一种名为埃博拉是肆虐西非，造成了至少700多人死亡，全世界严阵以待，包括中国在内的很多国家已经紧急收紧边境，尤其对从非洲地区回国的人员更是加强健康检测。
我们今天护理查房的对象是707床刘伟，患者曾在非洲安哥拉工作14个月，数月勤曾有疟疾数月前（在安哥拉期间）曾患有登革热，后治愈。
通过疟疾的护理查房。
希望大家了解疟疾的发生机制及其病理特点，熟悉疟疾的治疗原则，掌握疟疾患者的护理与观察要点，能够运用所学的知识对疟疾患者提供更好的、更有效的护理措施。
下面先请护师贾杨阳做病例介绍：一、病例介绍（一）病史患者刘伟，男，40岁，以“ 发热4天，伴黄疸进行性加重3天，意识障碍8小时”为代诉入院，家属代诉：患者于4天前，无明显诱因出现发热，当时未测体温，自行吃退热药后体温好转，夜间自觉体温好转，未再吃药。
患者于3天前，出现发热、，最高体温38.2℃，全身皮肤粘膜黄R染，进行性加重，至当地诊所治疗（不详），尿液逐渐变为茶色，呕吐3次，非喷射样，吐黄色水样物，腹泻，糊样便，遂至蒙城县人民医院门诊，给予对症处理后体温降至正常。
患者于8小时前出现意识障碍，呼之可睁眼，不能应答，急送至蒙城县人民医院ICU，当地医生建议转入我院。
Oncology department of Shanghai Shuguang Hospital Affiliated to shanghai University of TraditionalChinese MedicineThe scripts of Ward Round in English——R ectal Adenocarcinoma上海中医药大学附属曙光医院——肿瘤科英语查房剧本——直肠腺癌Chief: Dr.Zhong Yi 钟薏Attending Dr. Liu Hong Jie 刘宏杰Resident Dr. Zhang Yan Bo张彦博Intern Chen Xuan 陈旋Patient Shu Jia He 束家和A． Morning shift情景A：交班OFFICE:办公室Chief: ok! let's begin our morning shift.主任：好，现在开始晨交班。
Intern: DEC 10th 2007,morning shift. total number of the patients is 34,including 1 new admission, no critical patients. all the patients are in stable condition.the new admission in Bed No.12 is Mr. Wang yong,,male,61y.Who's chief complaint: low rectal adenocarcinoma ,received Mile’s operation 20days ago. diagnosis at present: low rectal adenocarcinoma.That's all for today's morning shift.实习医生：2007年12月10日晨交班，病人总数34人，新病人1人，危重病人0人，病人病情稳定。
