宫外孕英语查房

Gynecological Department of Shanghai Shuguang Hospital Affiliated to shanghai University of Traditional Chinese Medicine The scripts of Ward Round in English——Ectopic Pregnancy 上海中医药大学附属曙光医院 妇科 英语剧本——宫外孕 Director: Dr. Zhang Qinhua 张勤华 Attending: Dr. Hu Hui 胡慧 Resident: Dr. Shen Mingjie 沈明洁 Intern: Dr. Yi Yun 易云 Patient: Liujihong 刘继红 Glossary 词汇 ectopic pregnancy: 异位妊娠 P.I.D: pelvic inflammatory disease 盆腔炎 cervical lifting pain: 宫颈举痛 tenderness: 压痛 TVS: Transvaginal Ultrasound 经阴道超声 Cul-de-sac: 后穹隆 Culdocentesis: 后穹隆穿刺 Incoagulable blood: 不凝血 Initial impression: 初步诊断 Abdominal palpation: 腹部触诊 Rebound tenderness: 反跳痛 Percussion: 叩诊 Shifting dullness: 移动性浊音 Vaginal bleeding: 阴道出血 contraceptive users: 避孕药使用者 IUD: intrauterine device 宫内节育器 Intraperitoneal hemorrhage: 内出血 ampullary of fallopian tube: 输卵管壶腹部 corneal pregnancy: 宫角妊娠 Corpus luteum cyst rupture: 黄体破裂 Appendicitis: 阑尾炎 Salpingitist: 输卵管炎 Uterine abortion: 宫内妊娠流产 Threatened abortion: 先兆流产 Laparoscopy:腹腔镜 Laparotomy:剖腹手术 MTX: 氨甲喋呤 Mifepristione：米非司酮 A．Senior resident’s morning report 情景 A：交班 Good morning ,good morning. Director: Is everybody here? Others: yes. Director: OK, Dr. hu , let’s begin. Attending: Yes, The morning meeting now begins. Let’s have the report by the physician on call first. Dr Shen, Please? Resident: Last night ,there is no special thing happened except a new emergent patient. The patient named “Li Fang”, bed 6, 31-year-old, Hospital No. 10707890. She was admitted on 4 am, because of “severe low abdominal pain for 6 hours”. Our tentative diagnosis is: ectopic pregnancy. Now, the condition of the patient is stable. That’s all. 主治医师：请注意了, 交班开始。先请值班医师交班。 住院医师：昨晚没有特殊情况，除了一个急诊病人，病人姓名“李芳”6床，31岁，住院号： 10707890.今晨 4 点，患者因“下腹剧痛 6 小时”入院。初步诊断为异位妊娠，目前病人症 情平稳，交班完毕。 B．Case Presentation 情景 B: 病史汇报 Attending: OK, the first case of today’s Professor’s round is the new patient. Dr. shen, could you make a case report? 主治医师：好的，今天主任查房就从新病人开始。沈医生，你能汇报一下病史吗？ Resisdent: Yes. The key points of this case are : first, the patient is a 31-year-old married woman ,having the history of P.I.D one year ago. Secondly,She began to complain of acute low abdominal pain, especially in the left lower quadrant and became pale about 6 hours before admission , with nausea and vomiting. Her last menstrual period occurred 45 days before admission. Thirdly, the vaginal examination shows :normal size uterus ,cervical lifting pain and severe tenderness on the left side of the pelvis . 住院医师：是。本病例的特点是：1.该病人为 31 岁，已婚女性，一年前曾有盆腔炎病史。 2.患者因急性下腹痛，左侧痛甚，面色苍白伴恶心呕吐 6 小时入院。末次月经为入院前 45 天。3.阴道检查提示子宫正常大小，宫颈举痛，左侧附件明显压痛。 Director: what about the laboratory examination and the ultrasound of pelvis? 主任医师：实验室检查和盆腔 B超检查呢？ Resisdent: Yes, her laboratory examines were all within normal limits except that her urine pregnancy test is positive. TVS shows :there are an empty uterus ,free fluid in the cul-de-sac and a lump of 3cm in diameter on the left side. 住院医师：除尿妊娠试验阳性外，其它实验室检查均正常。阴超提示，宫内未见孕囊，后穹 隆积液，左侧附件发现一 3cm包块。 Director: Did you make the culdocentesis to make sure the character of the fluid ? 主任医师：你有没有做后穹窿穿刺以明确后穹窿积液的性质？ Resisdent: Yes, I did. the culdocentesis is positive , I drew the incoagulable blood from the pelvis. So our initial impression of the case would be ectopic pregnancy. And we have engaged an operation this noon. 住院医师：是的，后穹窿穿刺阳性，我抽出来自盆腔的不凝血。所以我们对该病例的初步诊 断是异位妊娠，并已预约今日中午手术。 Director: Okay, Dr.shen have made a perfect case report just now. next,lets go to the ward and look at the patient. 主任医师：感谢沈医师做了精彩的病例汇报，然后我们去病房看看患者。 C．Professor’s Ground 情景 C：主任查房 场景：病房 Director: Hello, LIFANG, I am Dr. Zhang. What’s your feeling now? Do you have pain, vaginal bleeding,or sick and so on? 主任医师：你好，李芳，我是张医师，你现在觉得怎么样，有没有肚子疼或者出血、恶心？ Patient: Hi, doctor. I just feel pain in my belly, and feel sick. 病人：你好，医生。我就是觉得肚子痛而且恶心。 Director: ok, ler’s make an examination, Dr Yi, please do the abdominal palpation. I主任医师：我们做一下体格检查，易医生，你能做一下腹部触诊。 Intern: Yes, bent you knees, please. Do you feel pain,(Yes) Here? (Yes a little) There?(Yes.) Severe or not?(Severe) . 实习医师：蜷一下腿。这里痛吗（痛的），这里呢？（一点点），那里（痛），痛的厉害吗？ （厉害的） Intern:(Face to the director): the abdomen is soft ,the tender point is in the left side. 实习医师：（面对主任）：腹软，左侧压痛。 Director: Dr Yi, you missed some important steps in the examination , Follow Me. Firstly , we touch the general abdomen gently ,to feel it is soft or rigidity, the goal of palpation is to find Where is the tender point? Is there muscle guarding ? Is there rebound pain? For this patiient , admonen is soft, and the maximal tender point is in the left side, no musle guarding and then ,we should make the percussion of the abdomen (make it when flat,and percuss the left. )Turn right please ,ok ,that’s all . the shifting dullness ispositive. Do you get it? 主任医师：易医生，你遗漏了体检中的一些重要步骤，看我做。首先，我们轻触诊全腹，感 觉腹部是柔软还是僵硬，触诊的目的是寻找哪里是压痛点？有没有肌卫？有没有反跳痛？ 这个病人，腹部视柔软的，最明显的压痛点在盆腔，没有肌卫。我们还需要做叩诊，请往左 侧翻身。做完了。移动性浊音是阳性的。你明白了吗？ Intern: Yes, I do ,thank you , director. 实习医师：是的，谢谢主任。 Director: OK,that’s all. Your condition is not serious, so take it easy and have a rest, today you will have an operation, don’t worry, everything will be okay. 主任医师：好的，你的情况不是很严重，不要紧张，好 好休息。今天你要动个手术，不要 担心，一切都会好的。 Patient: doctor, well, can I have chance of pregnancy after operation? 病人：医师，我手术后还能怀孕吗? Director: don’t worry about it ,we will try out best to keep your ability of pregnancy if the condition is allowed, Take ease. 主任医师:不用担心，如果情况允许的话，我们会尽量保留你的生育能力，放松些。 Patient: Thank you, doctor. 病人:谢谢你，医生。 Director：ok,let’s back to the office. 主任医师：好的，我们先回到办公室。 D.Discussion 情景 D: 病例讨论 场景：医生办公室 Director: let’s talk about the case. Dr. Shen, Could you tell me why did you make a diagnose of ectopic pregnancy in this case ? 主任医师：我们讨论一下这个病例，沈医生，你能说一下你为什么诊断她异位妊娠吗？ Resident: Well, “missed period ,abdominal pain and vaginal bleeding” is the three typical syndromes of ectopic pregnancy. For this patient, we have two. And Vaginal examination shows normal size uterus but cervical lifting pain and severe tenderness on the left side. The urine pregnancy test is positive, but TVS shows an empty uterus ,a lump of 3cm in diameter on the left side and free fluid in the cul-de-sac, .Especially culdocentesis is positive. So I think the evidence of ectopic pregnancy is enough. Am I right,director? 住院医师：好的。“停经，腹痛，阴道出血”这是三个异位妊娠的经典症状。这个病例有其 中的两个。同时阴道检查提示子宫正常大小，但有宫颈举痛，左侧附件压痛。尿妊娠试验阳 性，但阴超提示宫内未见孕囊，左侧附件 3cm 大小包块，后穹窿积液，尤其是后穹窿穿刺 阳性。所以我认为异位妊娠的依据是足够的。主任，我的说法正确吗？ Director: Absolutely right! Dr. Shen, could you tell me what are the high risk factors of the ectopoic pregnancy? 主任医师：非常正确。沈医生，那你认为哪些是异位妊娠的高危因素呢？ Resident: pelvic operation history, pelvic inflammation 住院医师：盆腔手术史，盆腔感染 Attending: And contraceptive users, IUD(intrauterine device) are also the high risk factors. 主治医师：还有避孕药使用者，以及宫内节育器使用者。 Director: very good, look at this patient, she had the P I D history one year ago ,so it maybe the cause of this ectopic pregnency. Dr. Yi, do you think this patient had an intraperitoneal hemorrhage？ 主任医师：很好，看一下这个病例，这个病人一年前曾患盆腔炎，这可能是这次宫外孕的诱 因。易医生，你觉得这个病人有内出血情况吗？ Intern: yes I think so . 实习医师：我认为有的。 Director:Why? 主任医师：为什么呢？ Intern: Abdominal pain, tenderness and rebound tenderness, cervical lifting pain,and TVS shows there was free fluid in the cul-de-sac all suggest intraperitoneal hemorrhage. 实习医师：腹痛，压痛，反跳痛，B超提示后穹隆积液均提示内出血。 Director: good, Dr. Hu, What’s your opinion? 主任医师：好的，胡医生，你的意见呢？ Attending: ‘‘Abdominal pain, absence of bowel sounds, tenderness,rebound tenderness,cervical lifting pain, shifting dullness’’all suggest intraperitoneal hemorrhage. In this case ,the most important and derect evidence is culdocentesis , last night Dr. Shen got the incoagulable blood which make sure there is intraperitoneal hemorrhage. 主治医师：“腹痛，压痛，反跳痛,宫颈举痛,移动性浊音”均提示内出血,在这个病例中，后 穹窿穿刺是最重要和最直接的证据。抽出不凝血证实了腹腔内出血的存在。 Intern : how to judge the amout of intraperitoneal hemorrhage ? 实习医师：那如何判断内出血量呢？ Attending: How to evaluate the condition of intraperitoneal hemorrhage is very important in every ectopoic pregnancy case. If there are faint, less amount of urine, heart rate accelerates, shoulder and flank pain, we must pay attention to theses signals of large amount of intraperitoneal hemorrhage. They means to have an operation as soon as you can. 主治医师：在异位妊娠病例中，评估内出血的情况是非常重要的。如果出现晕厥，少尿，心 率上升，肩部及胁部疼痛，我们必须意识到这些可能是大量内出血的征兆，这意味着尽快手 术。 Director: I greatly appreciate what doctor hu had said, a large amout of intraperitoneal hemorrhage is a very important symbol for emergency operation. So Dr. Yi, could you tell me what is the position such pregnancies occur? 主任医师：我非常赞同胡医生的观点，大量腹腔内出血是急诊手术的重要指标，那么，易医 生，异位妊娠的好发部位是哪里？ Intern: The ampullary of fallopian tube. 实习医师：输卵管壶腹部。 Director: Yes! Over 90 percent of such pregnancies occur in the fallopian tube, typically in its ampullary portion. In the remaining cases the pregnancy is located outside the tube, most frequently at an ovarian, abdominal, or cornual site. And cornual pregnancy is very dangerous.Dr shen ,could you tell us why it is dangerous ？ 主任医师：对。90％以上的异位妊娠发生在输卵管，尤其是壶腹部。其余异位灶位于输卵管 外，通常于卵巢，腹腔，或者宫角部。宫角妊娠是非常危险的, 沈医生，你能告诉我们为什 么吗？ Resistent: Because of a large amount of intraperitoneal hemorrhage would happened sunddenly in the cornual pregnancy and leads to severe shock, even to death. 住院医师：因为它可能引起突发性大量内出血，导致严重的休克，甚至死亡。 Director: Yes，absolutely right. so doctorYi, could you tell me what’s the most common dieases in the differential diagnosis of ectopic pregnancy? 主任医师：没错，易医生，你能说一下异位妊娠最重要和什么来鉴别？ Intern: Corpus luteum cyst rupture. 实习医师：黄体破裂。 Director: anything else？ 主任医师：还有吗？ Resident: And appendicitis , salpingitist 住院医师：还有阑尾炎，输卵管炎。 Attending: uterine abortion are most common. 主治医师：宫内妊娠流产也是常见的鉴别诊断。 Director:very good. 主任医师：回答的很好。 Intern: Can I ask a question? How to differentiate ectopic pregnancy between threatened abortion? 实习医师：我能问一个问题吗？如何鉴别异位妊娠和先兆流产？ Director: dr hu , can you answer this question for her? 主任医师：胡医师，你能解答她的问题吗？ Attending: Yes ,they both have syndromes of low abdominal pain, vaginal bleeding, and missed period. The pregnancy tests are positive ,either. In these cases Blood β-HCG is very important to us. As a rule, the β-HCG concentration doubles about every one to three days during a normal pregnancy. In two thirds of ectopic pregnancies, in contrast, the β-HCG concentration doubles at a slower rate, plateaus, or falls. Tvs is highly accurate in differential diagnosing, too. 主治医师：是的，两者均有下腹痛，阴道出血，停经的症状，妊娠实验也都是阳性的。在这 些病例中，血β-HCG 对我们就十分重要了。一般在正常妊娠过程中，β-HCG 浓度每隔一 至三天便会加。相反，在三分之二的异位妊娠中，β-HCG的浓度以先缓慢速度加倍，然后 出现平坡，或下降。B超在鉴别诊断中也是相当精确的。 Director: Do you get it ？ 主任医师：你明白了吗？ Intern：Yes I see. Can I ask another question？how many methods are there to treat the ectopic pregnancy? 实习医师：是的，我明白了，我能再问个问题吗？异位妊娠有哪些治疗方法？ Director: The treatment of ectopic pregnancy is divided into two differen methods, one is the surgical method and th other is medical method. The surgical method also divided into laparoscopy and laparotomy. Dr hu, can you introduce it in detail for us? 主任医师：异位妊娠治疗可分为手术和药物治疗两种。对于破裂型，腹腔内出血患者需要急 诊手术，手术方式分为腹腔镜和开腹两种。胡医生，你能为我们具体介绍一下吗？ Attending : Yes, if the tube is ruptured and there is intraperitoneal hemorrhage, the patient needs emergency operation. We can select the laparoscopy or transabdominal operation. Whether to preserve the tube or not depends on the requiration of the reproductive ability. If the tube is unruptured and the lump is small , the β-HCG is low, we can choose the MTX(methotrexate) or mifepristone to treat the patient, but we need to test the hcg level dynamiclly. 主治医师：是的，如果输卵管破裂并且存在内出血，那病人需要急诊手术。我们可以选择腹 腔镜或是开腹手术。是否保留输卵管视患者是不是要求保留生育能力而定。对于未破裂的， 包块较小，hcg水平较低的患者，可以采取保守治疗，我们主要通过注射 MTX或者口服米 非司酮，并监测 HCG水平观察效果。 Intern:: I see 。how about the prognosis of the ectopic pregnancy? Is there any chance for the patient to have normal pregnancy？ 实习医师：我明白了，那么异位妊娠的预后如何？患者还有正常怀孕的机会吗？ Director: generally, the hCG level will need to be rechecked on a regular basis until it reaches normal if we did not removed entire fallopian tube .if hCG level remains high may indicate the ectopic tissue was not entirely removed, which would require medical management again. The chances of having a successful pregnancy after an ectopic pregnancy may be lower than normal, but this will depend on why the pregnancy was ectopic and the medical history. The patient has approximately a 60% chance of having a successful pregnancy in the future..but ther is a risk of A repeated ectopic pregnancy may occur in 10 - 20% of cases. 主任医师：如果保留输卵管的手术，通常我们会定期监测血 HCG水平直至正常范围，如果 hcg水平保持较高水平可能提示孕囊残留，需要再次药物治疗。一般而言，宫外孕患者正常 妊娠的机会会比正常人小，当然也会视引起宫外孕的原因及治疗方法不同。大约 60%的患 者会成功妊娠，但也有 10-20%的患者会再次发生宫外孕。 Director: Do you have any question? ok，let’s come back to this patient,. Dr. Shen, what is our treatment to this patient? 主任医师：还有问题吗？好，我们再回到这个病例上，沈医生，我们如何治疗这个病人？ Resident: We have made an appointment of laparoscopic operation in 11:00. If this is an unruptured ectopic pregency , we will choose the method of preserving the fallopian tube. 住院医师：我们已经预约今日 11:00行腹腔镜手术。如果该病例是未破裂型异位妊娠，我们 将选择保留输卵管的术式。 Director: All right, I agree with your opinions of diagnosis and operation method. It’s a typical case of ectopic pregnancy. Now you can go to tell the patient and her family our decision and ask for their opinions. 主任医师：很好，我同意你们的诊疗意见。这是一个典型异位妊娠病例。现在你去告诉病人 和家属我们的决定并征求他们的意见。 Attending: Yes, director. Thank you for your calling on this patient. Let’s go on the next patient. 主治医师：是的，主任，谢谢你看这个病人，让我们看下一个病人。