本书专门为神经外科方向的住院医师和专科医师的临床应用编写。全书共分为8个章节, 主要内容包括特殊医疗用词与生活用词应用区别、医疗环境的物品表达、各类医疗文书撰写方法、医患沟通技巧、体格检查步骤、病例讨论材料准备、手术记录描述、学术思想交流等方面。
王向宇 教授、主任医师。正高3级。医学博士。硕士生导师、博士生导师、博士后导师。日本香川医科大学留学。上海中欧国际工商学院医院管理文凭班毕业。
Chapter 1 Introduction to the Human Body
1.1 Information Box/ / 2
1.2 Medical Terminology of the Body: Directional/2
1.2.1 Medical Terminology of the Body: Anterior (Front) View/ 4
1.2.2 Medical Terminology of the Body: Posterior (Back) View/ / 6
1.3 Grammar Tip: Collocations/ / 7
1.4 Cross-Cultural Awareness/7
1.5 Case Study/ 7
Chapter 2 Medical History Taking
2.1 Information Box/ 10
2.2 Summary of Medical Terminology Versus Everyday Term in Recording MedicalHistory/ 11
2.3 Introducing Yourself: Social Introduction Versus Professional Introduction/ / 12
2.3.1 Greeting in a Social Environment/ / 13
2.3.2 Greeting in a Professional Environment/ 13
2.4 Starting the Patient Interview: Asking Questions Used During a Patient Interview/ 14
2.4.1 Types of Questions Which are Used During a Patient Interview/ / 14
2.4.2 Asking for Patient Details/ 15
2.4.3 Asking a Patient to Repeat Information Review These Phrases/ / 16
2.4.4 Asking a Patient Why They Have Come to Hospital Review These Phrases/ 16
2.4.5 Patient Centered Interview Versus Doctor Centered Interview/ 16
2.4.6 Explaining Medical Terminology to Patients/ 17
2.5 Grammar Tip: Prepositions/ / 17
2.6 Cross-Cultural Awareness/ 18
2.7 Case Study: Doctor and Patient Dialogue / 19
3 Examining the Patient (Physical Examination)
3.1 Information Box/ 24
3.2 Medical Terminology Related to the Nervous System/ / 25
3.3 General Physical Examination/ 27
3.4 Neurological Examination/ 28
3.4.1 Mental Status/ 28
3.4.2 Meningeal Irritation/ / 29
3.4.3 Check neck stiffness, Kernig’s sign, and Brudzinski’s sign/ / 29
3.4.4 Cranial Nerves (CN)/ 29
3.4.5 Motor Examination/ 30
3.4.6 Sensory Examination/ 30
3.4.7 Reflexes/ / 30
3.4.8 Coordination and Gait/ / 31
3.5 Special Signs and Other Tests/ 31
3.5.1 Primitive Reflexes/ 31
3.5.2 Superficial Reflexes/ / 32
3.5.3 Test for Meningeal Irritation/ 32
3.5.4 Miscellaneous Tests/ 33
3.5.5 Grading Systems to Predict the Rate of Mortality in Cerebrovascular Diseases/ 34
3.6 Grammar Tip: Articles/ / 36
3.7 Cross-Cultural Awareness/ 37
3.8 Case Study: Case Presentation and Summary/ 37
Chapter 4 Writing Medical Records
4.1 Information Box/ 43
4.2 Grammar Tip: the Article “the”/ 43
4.3 Cross-Cultural Awareness/ 44
4.4 Case Study: Case Presentation/ / 44
Clinical Presentation/ 44
4.4.2 Case Summary and Synthesis/ 45
4.4.3 Neurosurgical Cases/ 45
Chapter 5 Special Medical Documentations
5.1 Information Box/ 56
5.2 Grammar Tip: Singular and Plural/ / 56
5.3 Culture Awareness/ 57
5.4 Consultation Request Note/ / 57
5.5 Informed Consent/ 58
5.6 Operative Notes/Operative Report/ 59
5.6.1 Pre-Operative and Post-Operative Note/ / 60
5.6.2 Neurosurgery Informed Consent Form/ 61
5.6.3 Surgical Risks Assessment Form/ / 63
5.6.4 Surgical Safety Check List/ / 66
5.6.5 Blood Transfusion Request Form/ / 67
5.6.6 Pathology Request Form/ 68
5.7 Prescriptions Form and Doctor’s Order/ / 69
5.8 Progress Notes/ / 70
5.9 Referral Form/ 71
5.10 Discharge Note/Discharge Summary/ / 72
5.11 Medical Report/ 73
5.12 Death Certificate, Morbidity and Mortality Review/ 74
Chapter 6 Writing Case Report
6.1 Information Box/ 76
6.2 Grammar Tip: Subject Verb Agreement/ / 76
6.3 Cross-Cultural Awareness/ 77
Principles of Writing Medical Case Report/ 77
6.5 Preparation of Manuscript Sections for Case Reports/ 79
6.6 Preparing Illustrations and Figures/ 84
6.6.1 Figure / 84
6.6.2 Illustration/ / 84
6.6.3 Legend/ / 84
6.7 Preparing Tables/ / 85
6.8 Preparing Additional Files / / 85
6.8.1 Style and Language/ 86
6.8.2 Language Editing/ 86
6.8.3 Abbreviation/ / 86
6.8.4 Case Overview/ / 86
6.9 Submission Process/ 86
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