病史書(shū)寫(xiě)2-朱偉

1、體格檢查(二）,Inspection：腹紋：abdominal striae外形：contour膨脹：distension平坦的：flat腹脹不對(duì)稱：asymmetrical distension蛙腹：frog belly腹部普遍膨?。ò枷荩篻eneral prominenoe (retraction) of the abdomen,五、腹部 Abdomen,Inspect

2、ion：腹圍增大：increased abdominal girth腸型：intestinal pattern (or contour)階梯樣蠕動(dòng)波：peristaltic wave in ladder pattern臍膨出：projection of the umbilicus膨隆的：protuberant舟狀腹：scaphoid abdomen妊娠紋：striae gravidarum

3、striae of pregnancy靜脈曲張：varicose veins; dilated tortuous veins；varicoaty可見(jiàn)胃蠕動(dòng)：visible gastric peristalsis,Inspection：1. Inspection reveals visible peristaltic waves passing from left to right across the upper a

4、bdomen.2. Findings on inspection are a distended abdomen covered by tense, shiny skin.3. ln the upper abdomen, dilated tortuous veins are seen in which the blood flows upwards,,Palpation：板樣強(qiáng)直:board-like rigidity

5、肝脾腫大：hepatosplenomegaly肝腫大：hepatomegaly；enlargement of the liver腹壁松弛：lax abdominal wall墨菲(氏)征：Murphy‘s sign肌衛(wèi)：muscle guarding反跳痛：rebound tenderness強(qiáng)直：rigidity脾腫大：splenomegaly;enlargem

6、ent of the spleen壓痛：tenderness,Palpation：1. Rebound tenderness and board-like rigidity of the abdominal musculature are present in all abdomen2. The patient has a palpable loop of thickened bowel in the left lower

7、 quadrant3. A firm tumor mass, about 3 cm in diameter, is felt 4 centimeters below the costal margin at the external margin of the right rectus muscle,Percussion：濁音：dullness移動(dòng)性濁音:shifting dullness鼓音：tyrnpani

8、tic resonance；1. Percussion of the abdomen demonstrates tympany throughout2. There is no shifting dullness3. On percussion there is dullness in the flanks and tympanitic in the middle,Auscultation：濁音：dullness

9、腸鳴：Borborygmi擊水聲：splashes腸鳴音：bowel soundsperistaltic sounds氣過(guò)水聲：gurgling；borborygmus of bubbling quality振水聲：succusion sound；clapotage；clapotement,外展：abduction指端肥大：acromegaly內(nèi)收：add

10、uction關(guān)節(jié)強(qiáng)硬:ankylosis髁關(guān)節(jié)強(qiáng)硬：ankylopodia前屈：anteflexion撕脫：avulsion胼胝：callus杵狀指：clubbing； clubbed finger骨性強(qiáng)直：bony ankylosis,六、Extremity and spine,褥瘡：decubitus；bedsore脊柱畸形：deformity of spin

11、e背側(cè)屈曲：dorsiflexion伸直：extension屈曲：flexion前屈：forward bending膝內(nèi)翻：genu varum; bowleg膝外翻：knock-knee; genu valgus脊柱后凸（駝背）：kyphosis；rachiocyphosis側(cè)彎：lateral bending；脊柱前凸：lordosis,跛行：limping；limp脊

12、柱前側(cè)突：lordoscoliosis平足：pes planus; flat foot足外翻：pes valgus足內(nèi)翻：pesvarus凹陷性水腫：pitting (brawny) edema多指（趾）：polydactylia旋前：pronation脊柱側(cè)凸：scoliosis旋轉(zhuǎn)：rotation脊柱后側(cè)凸：scoliokyphosis,脊柱左側(cè)凸：scolio

13、sis with a convexity to the left side瘺管形成：sinus tract formation關(guān)節(jié)僵硬：stiff-joint背部僵硬：stiffness of the back旋后：supination并（指）趾：syndactyly腹側(cè)屈曲：ventriflexion垂腕：wrist drop,感覺(jué)異常：perverted sensation；pare

14、sthesia指端感覺(jué)異常：acroparesthesia痛覺(jué)缺失：alganesthesia對(duì)側(cè)感覺(jué)：allochiria觸覺(jué)遲鈍：amblyaphia感覺(jué)喪失：anesthesia實(shí)體覺(jué)喪失：astereognosis味覺(jué)遲鈍：amblygeustia束帶狀感覺(jué)：cincture sensation;girdle sensation；zonesthesia,七、Nerve a

15、nd Muscle,蟻?zhàn)吒校篶reeping sensation；formication平衡感：equilibrium sense； static sense味覺(jué)：gustatory sense；taste sense感覺(jué)減退：hypoesthesia；hyperesthesia運(yùn)動(dòng)覺(jué)：kinesthetic sensations冷幻覺(jué)：paradoxical cold sens

16、ations壓覺(jué)：pressure sense；姿勢(shì)覺(jué)：posture sense,本體感覺(jué):proprioceptive sense；溫覺(jué):sensations of warmth；thermic sense空間覺(jué):space sense實(shí)體覺(jué):stereognostic sense緊張感覺(jué):strain sensations觸覺(jué):tactil sensations麻刺感

17、:tingling震動(dòng)覺(jué):vibratory sense,交叉性癱瘓：alternate paralysis麻醉后麻痹：anesthesia paralysis聯(lián)合麻痹：association paralysis 延髓性麻痹：bulbar paralysis撲翼樣震顫：asterixis無(wú)力性延髓麻痹：astheno-bulbospinal paralysis；bulbospinal para

18、lysis手足徐動(dòng)癥：athetosis手足搐搦：tetany,共濟(jì)失調(diào)：ataxia產(chǎn)傷麻痹：birth paralysis行走徐緩：bradybasia中樞性麻痹：central paralysis舞蹈樣運(yùn)動(dòng)：choreiform movement同向性麻痹：conjugate paralysis；symparalysis面神經(jīng)麻痹：facial paralysis弛緩性麻痹：flacci

19、d paralysis全身性麻痹：general paralysis；general paralysis of the insane偏癱：hemiplegia,不全麻痹：incomplete paralysis；paresis小兒麻痹，脊髓灰質(zhì)炎：infantile paralysis不隨意運(yùn)動(dòng)：involuntary movement單癱：monoplegia肌纖顫：muscular

20、 fibrillation肌陣攣：myoclonus麻痹：paralysis截癱：paraplegia,跟腱反射：achilles tendon reflex肛門(mén)反射：anal reflex股二頭肌反射：biceps femoris reflexes肱二頭肌反射：biceps jerk reflexes擁抱反射：clasping reflex；embrace reflex；Moro‘s r

21、eflex結(jié)膜反射：conjunctival reflexes角膜反射：corneal reflex咳嗽反射：cough reflex提睪反射：cremasteric reflexes光反射：light reflex瞳孔反射：pupillary reflex,跟腱反射：achilles tendon reflex肛門(mén)反射：anal reflex股二頭肌反射：biceps femoris

22、 reflexes肱二頭肌反射：biceps jerk reflexes擁抱反射：clasping reflex；embrace reflex；Moro‘s reflex結(jié)膜反射：conjunctival reflexes角膜反射：corneal reflex咳嗽反射：cough reflex提睪反射：cremasteric reflexes光反射：light reflex瞳孔反射：

23、pupillary reflex,Blood：紅細(xì)胞計(jì)數(shù)：red blood cell count血紅蛋白定量分析：measurement ofhemoglobin紅細(xì)胞比積：hematocrit(Hct)白細(xì)胞計(jì)數(shù)：white blood cell count白細(xì)胞分類計(jì)數(shù)：white blood cell differential count嗜酸粒細(xì)胞計(jì)數(shù)：eosinocyte coun

24、t平均紅細(xì)胞容積：mean corpuscular volume(MCV),Lab examination,平均紅細(xì)胞血紅蛋白含量：mean corpuscular hemoglobin (MCH)平均紅細(xì)胞血紅蛋白濃度：mean corpuscular hemoglobin concentration(MCHC)平均紅細(xì)胞直徑：measurement of red cell diameter網(wǎng)織紅細(xì)胞計(jì)

25、數(shù)：reticulocyte count紅細(xì)胞形態(tài)觀察：morphologic observation of red blood cell巨紅細(xì)胞：megalocyte,球形紅細(xì)胞：spherocyte橢圓形紅細(xì)胞：elliptocyte靶形紅細(xì)胞：target cell鐮形紅細(xì)胞：sickle cell棘形紅細(xì)胞：acanthocyte淚滴狀紅細(xì)胞：cacryocyte裂片細(xì)胞：

26、schistocyte口形紅細(xì)胞：stomatocyte皺縮紅細(xì)胞：crenocyte低色素性小紅細(xì)胞：hypochromic microcyte,嗜堿性點(diǎn)彩紅細(xì)胞：basophilic stippling cell有核紅細(xì)胞：nucleated erythrocyte緡錢(qián)狀形成：rouleaux-formation染色體小體：Howell-JoUy bodies卡波氏環(huán)Cabot‘s ri

27、ng紅細(xì)胞沉降率：erythrocyte sedimentation rate(ESR),Bone Marrow：原粒細(xì)胞：Myeloblast早幼粒細(xì)胞：Promyelocyte中幼粒細(xì)胞：Myelocyte晚幼粒細(xì)胞：Metamyelocyte桿狀核粒細(xì)胞：band form多形核粒細(xì)胞：polymorphonuclears中性粒細(xì)胞：neutrophil嗜堿性粒細(xì)胞：bas

28、ophil嗜酸性粒細(xì)胞： eosinophil,原紅細(xì)胞：Pronormoblast早幼紅細(xì)胞：basophilic pronormoblast中幼紅細(xì)胞：polychromatophilic normoblast晚幼紅細(xì)胞：orthochromatic normoblast原淋巴細(xì)胞：lymphoblast幼淋巴細(xì)胞：prolymphocyte淋巴細(xì)胞：lymphocyte原單核細(xì)胞：mo

29、noblast幼單核細(xì)胞：promonocyte單核細(xì)胞：monocyte,原漿細(xì)胞：plasmablast幼漿細(xì)胞：proplasmacyte漿細(xì)胞：plasma cell網(wǎng)狀細(xì)胞：reticular cell原巨核細(xì)胞：megakaryoblast幼巨核細(xì)胞：promegakaryocyte顆粒巨核細(xì)胞：granular megakaryocyte產(chǎn)血小板顆粒細(xì)胞：platele

30、t-producingmegakaryocyte裸核巨細(xì)胞：”bare-nucleus" form of megakaryocyte,血小板計(jì)數(shù)：platelet count出血試驗(yàn)：bleeding time血小板粘附性試驗(yàn)：platelet adhesivenesstest血小板聚集性試驗(yàn)：platelet aggregation test血塊收縮定量測(cè)定：clot retra

31、ction quantitative assay凝血時(shí)間：coagulation time復(fù)鈣時(shí)間：recalcification time復(fù)鈣時(shí)間交叉試驗(yàn)：cross test of recalcification time,活化凝血時(shí)間：activated coagulation time白陶土部分凝血活酶時(shí)間：kaolin partial thromboplastin time（KPTT）

32、KPTT糾正時(shí)間：correction test of KPTT凝血酶原消耗試驗(yàn)：prothrombin consumption test凝血酶原生成試驗(yàn)：Biggs thromboplastin generation test簡(jiǎn)易凝血活酶生成試驗(yàn)：simple thromboplastin generation test,尿素氮測(cè)定：urea nitrogen assay肌酐測(cè)定：creatinine

33、assay尿酸測(cè)定：uric acid assay氨基酸氮測(cè)定：amino acid nitrogen assay內(nèi)生肌酐清除試驗(yàn)：endogenous creatinine clearance test 尿素清除試驗(yàn)：urea clearance test酚紅排泄試驗(yàn)：phenolsulfonphthalein exctetion test對(duì)氨馬尿酸清除試驗(yàn)：paraaminohi

34、ppurate clearance test;,谷丙轉(zhuǎn)氨酶：glutamic pyruvic transaminase谷草轉(zhuǎn)氨酶：glutamic oxalo-acetic transaminase血清精氨酰琥珀酸裂解酶：serum argino succinatelyase血清谷氨酸脫氫酶：serum glutamic dehydrogenase血清山梨醇脫氫酶：serum sorbitol dehydro

35、genase血清鳥(niǎo)嘌呤酶：serum guanine deaminase,血清堿性磷酸酶：serum alkaline phosphatase血清谷氨酰轉(zhuǎn)肽酶：serum gamma glutamyltranspeptidase血清5‘- 核苷酸酶：serum 5’-nucleotidase血清亮氨酸氨基肽酶：serum leucine aminopeptidase血清異檸檬酸脫氫酶：serum iso

36、critrate dehydrogenase血清腺苷脫氨酶：serum adenosine deaminase血清單胺氧化酶：serum monoamine oxidase,血清膽堿酯酶：serum cholinesterase血清蛋白：serum protein血清白蛋白：albumin血清球蛋白：globulin麝香草酚絮狀試驗(yàn)：thymol flocculation test麝香草酚濁度試

37、驗(yàn)：thymoturbidity test硫酸鋅濁度試驗(yàn)：zinc sulfate turbidity test血清膽紅素：serum bilirubin黃疸指數(shù)：icteric index,Physical examination of a healthy person,He is a middle developed and well-nourished 40 year-old man with blood p

38、ressure of 17. 3/10. 7KPa，a pulse of 80/min and respiration of 16/min. Active position. Free movement. There were no purpurae, jaundice or scar on his skin他是一位發(fā)育中等，營(yíng)養(yǎng)較好的40歲男性。血壓17.3/10.7KPa，脈搏80次/分，呼吸16次/分。自動(dòng)體位?；顒?dòng)自如。皮膚

39、無(wú)紫癜、黃疸或疤痕,General conditions,The shape of his head was normal. The hair was black and lustrous. The quality and distribution of axillary and pubic hair were normal. 頭顱外形正常，毛發(fā)黑、有光澤。腋毛和陰毛形狀和分布正常。,Head,Eyes : There was

40、no injection on the conjunctivae. Sclerae were not icteric ( anicteric). The pupils were round and equal, reactive well to light and accommodation 眼：結(jié)膜不充血，鞏膜無(wú)黃染。兩瞳孔等大、等圓。光反射和調(diào)節(jié)良好,Ears : No abnormal pinnae ( = auricl

41、es). The external canals were clear without pus. The tympanic membranees showed good light reflex, and neither injection nor perforation. Noraml hearing. No tenderness over the mastoids耳：耳廓正常。外耳道清潔，無(wú)膿液。鼓膜光反射良好，無(wú)充血、穿孔。

42、聽(tīng)力正常。乳突無(wú)壓痛。,Nose：The nose showed no deformity or flaringof the alae nosi. No bloody or pusy discharge. The turbinates were not hypertrophic. There was no diviation of the septum. No tenderness over the sinuses. The nas

43、olabial grooves wereequal bilaterally鼻：無(wú)畸形或鼻翼扇動(dòng)。鼻腔無(wú)血性或膿性分泌物。鼻甲不肥大。鼻中膈不偏移。副鼻竇無(wú)壓痛。兩側(cè)鼻唇溝對(duì)稱。,Mounth：The lips were red and moist. No cyanosis. All teeth were present and good. The tongue was thinly coated with normal pa

44、pillae. No petechiae and no ulcer in the mucosa. No injection on the pharynx. The tonsils were not hypertrophic 口：口唇紅潤(rùn)，無(wú)紫紺。牙齒完好。舌苔薄，乳頭正常。粘膜無(wú)出血點(diǎn)或潰瘍。咽不充血，扁桃體不肥大,Neck :Supple. The thyroid was not enlarged. The trachea w

45、as in the midline. Flat neck veins. Carotid pulsations were not marked頸：軟，甲狀腺不腫大。氣管居中。頸靜脈平坦，無(wú)明顯頸動(dòng)脈搏動(dòng)。,Breast :(Man) The breasts were male without masses or discharge.(Female) The breaste were normal female and pendu

46、lous, devoid of palpable masses. The nipples showed not discharge and retraction乳腺：男：正常男性乳房，無(wú)腫塊及分泌物。女：正常女性乳房，懸垂?fàn)睿从|及腫塊。乳頭無(wú)分泌物，不凹陷。,Chest,Inspection: The PMI ( point of maximum impulse) was in 5th left intercostal sp

47、ace inside of the mid clavicular line and not diffusePalpation: The PMI was equal to inspection. No thrill望診：心尖搏動(dòng)位于左鎖骨中線內(nèi)側(cè)第5肋間隙，不彌散。觸診：最強(qiáng)搏動(dòng)點(diǎn)與望診一致。無(wú)震顫。,Chest: Heart,Percussion:The heart percussed normal in size. Pictu

48、re as follows叩診：心臟濁音界大小正常，如下圖所示：,Chest: Heart,Auscultation: The heart sounds were strong & no splitting. A rate of 80/ nun. Cardiac rhythm was regular. No pathological murmurs. Only grade I /IV ,soft systolic mu

49、rmur at the apex,Chest: Heart,Inspection: The breathing was mainly thoracic in type. The chest movement was good. The rhythm was equal (regular) Palpation: The fremitus was equal bilaterallyPercussion: Both lungs were

50、 resonant. The right lower limits at the 9th costa and the left at the 10th posteriorlyAuscultation: Breath sounds were clear without pathological sounds or rales,Chest: Lung,Inspection： Flat. No scar and no dilated vei

51、n seenPalpation: Soft. No tenderness. No palpable masses or organomegalyPercussion: Tympanitic resonance. No shifting dullnessAuscultation: Normal bowel sounds ( No increased or decreased bowel sounds),Abdomen,Extremi

52、ties ( Limbs ):Free movement. No abnormality N. S. : ( Neural system)Physiological reflexes were present without pathological reflexesGenitourinary system: (Man)：Normal adult external genitalia of

53、man. No swelling testes or hydrocele Digital examination not done(Feman): Normal, married vulva. Vagina and uterus were not examined,Other systems,Complete History,Name: Li pingSex: MaleAge: 25ys Race:HanOccupati

54、on: workerMarried status: marriedAddress: No 2, Feng Yang road, BengbuDate of admission: March 15th, 1987Date of record: March 15th, 1987Offerer of medical history: patient himselfReliability of history: reliable,B

55、asic Information,C.C. (=Cheif complaint): Palpitation, breathlessness and edema fora weekP. I. ( = Present illness) : The patient came in this morning with gradually increasing palpitation and dyspnea of a week duratio

56、n. He can't recline,had to sleep on three pillows or to sit up in bed to catch his breath. In recent week, loss of appetite, urination decreased, only twice daily passing about 600ml. Edema bacame increasingly appare

57、nt in the lower limbs.,Arthralgia is often present in the last 10 years, especially in the knees, ankles and shoulder joints when it's cold. Antirheumatic therapy (included Aspirin and prednison etc. ) was given for

58、"Rheumatic fever“ 8 years ago."Rheumatic heart disease "was diagnosed when he was admitted to our hospital about one year ago,Operative history: Tonsillectomy was performed for chronic tonsillitis before

59、5 years.Infectious history (Contagious history) :He had contact with patient who had pulmonary tuberculosis tor a month abouthalf a year ago.Allergic history :He had no history of allergy to drugs.,Respiratory system:

60、 No history of hemoptysis, frequent coughor feverCirculatory system (Cardiovascular system): (He had) no palpitation and edema a year agoAlimentary system (= Digestive system) :No sour regurgitation, stomachache or

61、hematemesisGenitourinary system :No polyuria, urgency of micturition, urodynia or markedly decreased sexual desire (= urge).,Hematopoietic system: There was no history of subcutaneous bleeding or anemiaEndocrine syste

62、m: Drinking and eating were within normal. No tremor or excessive sweating Kinetic system ( Locomotor system of skeletal system):No restriction of the limb movementNeural system:No headache, paralysis or aphasia,Per

63、sonal history: He has been living here since he was born. Smokes an average of a packet of cigarettes daily for the past 7years. Didn't drink. He was not exposed to toxic substances in the couse of his work.He got

64、married at the age of eighteen. He has two childrenFamily history: His parents are living and well. There is no hypertension or diabetes in his family. His wife and two childrenare in good health. Grandfather died from

65、 uremia in 1982,Physical Examination,He is a well developed, poorly nourished with Bp 17.3/ 10. 7KPa,P 110/min and R 28/min. Orthopnea. Slight cyanosis in the lips. No sign of bleeding or anemia on the skin. Superficial

66、lymph nodes were not palpable,Head：Examinations of the hair, eyes, ears, nose and throat showed no visible abnormalityNeck：The neck was supple. No palpable thyroid gland. The trachea was not deviated,Physical Examinati

67、on,Lungs:Inspection：The chest was flat with normal contour. The respiration was accelerated mildlyPalpation：The fremitus was equal without exaggeration or diminutionPercussion：The chest was clear to percussionAuscult

68、ation：There were no rales,rhonchi, wheezes or rubs present,Physical Exam: Chest,Heart:Inspection：The apical beat was diffused and visible in the 4th and 5th interspace out of the left midclavicular line Palpation: Apex