本研究旨在應用文步分析(move analysis)探究病例(case presentation)之架構及其語言特徵 (language features)。此外，英文母語醫師(English-native physicians)及台灣醫師在病例寫作上之異同亦為探究主題。本研究期望透過具體的文步架構與語言分析為台灣醫學病例寫作教學帶來實質裨益。
本研究以醫學期刊之影響係數(impact factor, IF)與醫學專家之建議為標準，由國內外各兩本知名醫學期刊中挑選共40篇神經科病例報告(case report)建構語料庫，作為分析英文母語醫師及台灣醫師病例寫作之資料來源。研究方法除了與醫學專家共同合作，以人工標記文步(tag)，亦使用語彙分析軟體進行資料比對分析。分析結果再次與醫學專家討論並確認其正確性及實用性，以期提高研究結果之信度，並尋找差異點之可能影響因素。
本研究結果發現病例中共有九大文步，其中可再細分相關元素以架構出完整之病例。九大文步中以現病史(文步1)、理學檢查(文步6)、檢驗報告(文步7)及病程發展(文步8)為必備文步。九大文步中，國內外醫學期刊皆重視文步8，並以較高比重撰寫此部份。相較之下，國內醫學期刊對文步1中的「過去就醫紀錄」著墨較少。此外，本研究結果亦發現四項內含於各文步中之醫學寫作技巧佔極大比例(約80%)。此四項寫作技巧為：描述病情表現、描述醫師如何處置、呈現理學檢查以及呈現檢驗報告。本研究建議教學者可採用文步架構和四大寫作技巧為綱要，設計病例寫作教學課程。
在語言特徵方面，本研究發現國外病例報告較為簡要緊湊有條理，除了講究寫作邏輯之外，並採用以時間為主軸之寫作手法。因此，國外期刊通常會標示清楚的時間點以帶領讀者了解完整的病例，然而國內病例較缺乏明確的時間標示與寫作邏輯。此外，透過文步標記，研究者發現國外病例中一個T單位(T-unit)通常只表達單一文步；反之，國內病例中一個T單位較常涵蓋兩個以上文步，造成文句複雜冗長。此一寫作差異可能受到台灣醫師之母語影響。最後，在用字方面，本研究發現國內外病例主要之用字差異在於搭配詞 (collocation)使用，亦即英文母語醫師使用之搭配詞較為多元彈性，而台灣醫師使用之搭配詞較為侷限。
本研究建議文步分析結果可提供具體之病例寫作參考，俾使台灣醫師更快更精確掌握寫作要領。同時，教師可利用本研究發現之語言特徵，針對台灣醫師之寫作特性提供適切指導，提高教學效能。

Despite the long-standing interest in L2 writing, and the new academic trend of English for medical purposes, research studies that explore the language features of medical writing by physicians have been relatively scarce. In addition, little pedagogical instruction has been suggested for case report writing, not to mention instructions for a case presentation which is a core section within a case report. This study created a corpus of 40 case presentations from case reports in international and Taiwan-published medical journals. In addition, a hand-tagged move analysis and concordance programs were used to explore the structure of moves and language features written by L1 and L2 writers.
Nine moves of a case presentation were identified in this study, namely (1) history of present illness, (2) past history, (3) personal history, (4) family history, (5) drug history, (6) general physical examinations on admission, (7) general laboratory findings on admission, (8) clinical course after admission, and (9) medical records after discharge. The results indicate that international journals and Taiwan-published journals generally agree with the moves, while one international journal particularly focuses on Move 1. Besides the moves analysis, this study finds four key elements that occur frequently in case presentations, and they may become four topics in case presentation writing instruction. As for language features, this study proposes that the international journals have a more concise writing style with a clear chronological order, while the order of moves within Taiwanese case presentations is less clear. In addition, the case presentations of international journals usually express one move or step per one T-unit, while the case presentations of Taiwan-published journals combine more than one move or step into one T-unit. This feature may have been influenced by the writers’ L1. Lastly, the findings indicate that the use of collocations in the international journals varies whereas the collocations used in the Taiwan-published journals are comparatively limited. These findings indicate that the lexical instructions for case presentations should pay more attention to collocations.
The findings in this study are believed to be useful to non-native case report writers not only allowing them to gain a better understanding of international case presentations’ writing skills, but also giving them a better insight into the format of writing case presentations for publication.

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