课件：病史书写朱伟.ppt

体格检查 (二）,Inspection： 腹纹： abdominal striae 外形： contour 膨胀： distension 平坦的： flat 腹胀不对称： asymmetrical distension 蛙腹： frog belly 腹部普遍膨隆（凹陷）： general prominenoe (retraction) of the abdomen,五、腹部 Abdomen,Inspection： 腹围增大： increased abdominal girth 肠型： intestinal pattern (or contour) 阶梯样蠕动波： peristaltic wave in ladder pattern 脐膨出： projection of the umbilicus 膨隆的： protuberant 舟状腹： scaphoid abdomen 妊娠纹： striae gravidarum striae of pregnancy 静脉曲张： varicose veins; dilated tortuous veins；varicoaty 可见胃蠕动： visible gastric peristalsis,Inspection： 1. Inspection reveals visible peristaltic waves passing from left to right across the upper abdomen. 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： 板样强直: board-like rigidity 肝脾肿大： hepatosplenomegaly 肝肿大： hepatomegaly； enlargement of the liver 腹壁松弛： lax abdominal wall 墨菲(氏)征： Murphys sign 肌卫： muscle guarding 反跳痛： rebound tenderness 强直： rigidity 脾肿大： splenomegaly; enlargement of the spleen 压痛： tenderness,Palpation： 1. Rebound tenderness and board-like rigidity of the abdominal musculature are present in all abdomen 2. The patient has a palpable loop of thickened bowel in the left lower quadrant 3. 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： 浊音： dullness 移动性浊音: shifting dullness 鼓音： tyrnpanitic resonance； 1. Percussion of the abdomen demonstrates tympany throughout 2. There is no shifting dullness 3. On percussion there is dullness in the flanks and tympanitic in the middle,Auscultation： 浊音： dullness 肠鸣： Borborygmi 击水声： splashes 肠鸣音： bowel sounds peristaltic sounds 气过水声： gurgling；borborygmus of bubbling quality 振水声： succusion sound； clapotage；clapotement,外展： abduction 指端肥大： acromegaly 内收： adduction 关节强硬: ankylosis 髁关节强硬： ankylopodia 前屈： anteflexion 撕脱： avulsion 胼胝 ： callus 杵状指： clubbing； clubbed finger 骨性强直： bony ankylosis,六、Extremity and spine,褥疮： decubitus；bedsore 脊柱畸形： deformity of spine 背侧屈曲： dorsiflexion 伸直： extension 屈曲： flexion 前屈： forward bending 膝内翻： genu varum; bowleg 膝外翻： knock-knee; genu valgus 脊柱后凸（驼背）： kyphosis；rachiocyphosis 侧弯： lateral bending； 脊柱前凸： lordosis,跛行： limping；limp 脊柱前侧突： lordoscoliosis 平足： pes planus; flat foot 足外翻： pes valgus 足内翻： pesvarus 凹陷性水肿： pitting (brawny) edema 多指（趾）： polydactylia 旋前： pronation 脊柱侧凸： scoliosis 旋转： rotation 脊柱后侧凸： scoliokyphosis,脊柱左侧凸： scoliosis with a convexity to the left side 瘘管形成： sinus tract formation 关节僵硬： stiff-joint 背部僵硬： stiffness of the back 旋后： supination 并（指）趾： syndactyly 腹侧屈曲： ventriflexion 垂腕： wrist drop,感觉异常： perverted sensation； paresthesia 指端感觉异常： acroparesthesia 痛觉缺失： alganesthesia 对侧感觉： allochiria 触觉迟钝： amblyaphia 感觉丧失： anesthesia 实体觉丧失： astereognosis 味觉迟钝： amblygeustia 束带状感觉： cincture sensation; girdle sensation；zonesthesia,七、Nerve and Muscle,蚁走感： creeping sensation； formication 平衡感： equilibrium sense； static sense 味觉： gustatory sense； taste sense 感觉减退： hypoesthesia； hyperesthesia 运动觉： kinesthetic sensations 冷幻觉： paradoxical cold sensations 压觉： pressure sense； 姿势觉： posture sense,本体感觉: proprioceptive sense； 温觉: sensations of warmth； thermic sense 空间觉: space sense 实体觉: stereognostic sense 紧张感觉: strain sensations 触觉: tactil sensations 麻刺感: tingling 震动觉: vibratory sense,交叉性瘫痪： alternate paralysis 麻醉后麻痹： anesthesia paralysis 联合麻痹： association paralysis 延髓性麻痹： bulbar paralysis 扑翼样震颤： asterixis 无力性延髓麻痹： astheno-bulbospinal paralysis； bulbospinal paralysis 手足徐动症： athetosis 手足搐搦： tetany,共济失调： ataxia 产伤麻痹： birth paralysis 行走徐缓： bradybasia 中枢性麻痹： central paralysis 舞蹈样运动： choreiform movement 同向性麻痹： conjugate paralysis； symparalysis 面神经麻痹： facial paralysis 弛缓性麻痹： flaccid paralysis 全身性麻痹： general paralysis； general paralysis of the insane 偏瘫： hemiplegia,不全麻痹： incomplete paralysis； paresis 小儿麻痹，脊髓灰质炎： infantile paralysis 不随意运动： involuntary movement 单瘫： monoplegia 肌纤颤： muscular fibrillation 肌阵挛： myoclonus 麻痹： paralysis 截瘫： paraplegia,跟腱反射： achilles tendon reflex 肛门反射： anal reflex 股二头肌反射： biceps femoris reflexes 肱二头肌反射： biceps jerk reflexes 拥抱反射： clasping reflex； embrace reflex；Moros reflex 结膜反射： conjunctival reflexes 角膜反射： corneal reflex 咳嗽反射： cough reflex 提睾反射： cremasteric reflexes 光反射： light reflex 瞳孔反射： pupillary reflex,跟腱反射： achilles tendon reflex 肛门反射： anal reflex 股二头肌反射： biceps femoris reflexes 肱二头肌反射： biceps jerk reflexes 拥抱反射： clasping reflex； embrace reflex；Moros reflex 结膜反射： conjunctival reflexes 角膜反射： corneal reflex 咳嗽反射： cough reflex 提睾反射： cremasteric reflexes 光反射： light reflex 瞳孔反射： pupillary reflex,Blood： 红细胞计数： red blood cell count 血红蛋白定量分析：measurement of hemoglobin 红细胞比积： hematocrit(Hct) 白细胞计数： white blood cell count 白细胞分类计数： white blood cell differential count 嗜酸粒细胞计数： eosinocyte count 平均红细胞容积： mean corpuscular volume(MCV),Lab examination,平均红细胞血红蛋白含量： mean corpuscular hemoglobin (MCH) 平均红细胞血红蛋白浓度： mean corpuscular hemoglobin concentration(MCHC) 平均红细胞直径： measurement of red cell diameter 网织红细胞计数： reticulocyte count 红细胞形态观察： morphologic observation of red blood cell 巨红细胞： megalocyte,球形红细胞： spherocyte 椭圆形红细胞： elliptocyte 靶形红细胞： target cell 镰形红细胞： sickle cell 棘形红细胞： acanthocyte 泪滴状红细胞： cacryocyte 裂片细胞： schistocyte 口形红细胞： stomatocyte 皱缩红细胞： crenocyte 低色素性小红细胞： hypochromic microcyte,嗜碱性点彩红细胞：basophilic stippling cell 有核红细胞： nucleated erythrocyte 缗钱状形成： rouleaux-formation 染色体小体： Howell-JoUy bodies 卡波氏环 Cabots ring 红细胞沉降率： erythrocyte sedimentation rate(ESR),Bone Marrow： 原粒细胞： Myeloblast 早幼粒细胞： Promyelocyte 中幼粒细胞： Myelocyte 晚幼粒细胞： Metamyelocyte 杆状核粒细胞： band form 多形核粒细胞： polymorphonuclears 中性粒细胞： neutrophil 嗜碱性粒细胞： basophil 嗜酸性粒细胞： eosinophil,原红细胞： Pronormoblast 早幼红细胞： basophilic pronormoblast 中幼红细胞： polychromatophilic normoblast 晚幼红细胞： orthochromatic normoblast 原淋巴细胞： lymphoblast 幼淋巴细胞： prolymphocyte 淋巴细胞： lymphocyte 原单核细胞： monoblast 幼单核细胞： promonocyte 单核细胞： monocyte,原浆细胞： plasmablast 幼浆细胞： proplasmacyte 浆细胞： plasma cell 网状细胞： reticular cell 原巨核细胞： megakaryoblast 幼巨核细胞： promegakaryocyte 颗粒巨核细胞： granular megakaryocyte 产血小板颗粒细胞：platelet-producing megakaryocyte 裸核巨细胞： ”bare-nucleus“ form of megakaryocyte,血小板计数： platelet count 出血试验： bleeding time 血小板粘附性试验： platelet adhesiveness test 血小板聚集性试验： platelet aggregation test 血块收缩定量测定： clot retraction quantitative assay 凝血时间： coagulation time 复钙时间： recalcification time 复钙时间交叉试验： cross test of recalcification time,活化凝血时间： activated coagulation time 白陶土部分凝血活酶时间： kaolin partial thromboplastin time（KPTT） KPTT纠正时间： correction test of KPTT 凝血酶原消耗试验： prothrombin consumption test 凝血酶原生成试验： Biggs thromboplastin generation test 简易凝血活酶生成试验： simple thromboplastin generation test,尿素氮测定： urea nitrogen assay 肌酐测定： creatinine assay 尿酸测定： uric acid assay 氨基酸氮测定： amino acid nitrogen assay 内生肌酐清除试验： endogenous creatinine clearance test 尿素清除试验： urea clearance test 酚红排泄试验： phenolsulfonphthalein exctetion test 对氨马尿酸清除试验： paraaminohippurate clearance test;,谷丙转氨酶： glutamic pyruvic transaminase 谷草转氨酶： glutamic oxalo-acetic transaminase 血清精氨酰琥珀酸裂解酶： serum argino succinatelyase 血清谷氨酸脱氢酶： serum glutamic dehydrogenase 血清山梨醇脱氢酶： serum sorbitol dehydrogenase 血清鸟嘌呤酶： serum guanine deaminase,血清碱性磷酸酶： serum alkaline phosphatase 血清谷氨酰转肽酶： 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 血清异柠檬酸脱氢酶： serum isocritrate dehydrogenase 血清腺苷脱氨酶： serum adenosine deaminase 血清单胺氧化酶： serum monoamine oxidase,血清胆碱酯酶： serum cholinesterase 血清蛋白： serum protein 血清白蛋白： albumin 血清球蛋白： globulin 麝香草酚絮状试验： thymol flocculation test 麝香草酚浊度试验： thymoturbidity test 硫酸锌浊度试验： zinc sulfate turbidity test 血清胆红素： serum bilirubin 黄疸指数： icteric index,Physical examination of a healthy person,He is a middle developed and well-nourished 40 year-old man with blood pressure 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 他是一位发育中等，营养较好的40岁男性。血压17.3/10.7KPa，脉搏80次/分，呼吸16次/分。自动体位。活动自如。皮肤无紫癜、黄疸或疤痕,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. 头颅外形正常，毛发黑、有光泽。腋毛和阴毛形状和分布正常。,Head,Eyes : There was no injection on the conjunctivae. Sclerae were not icteric ( anicteric). The pupils were round and equal, reactive well to light and accommodation 眼： 结膜不充血，巩膜无黄染。两瞳孔等大、等圆。光反射和调节良好,Ears : No abnormal pinnae ( = auricles). 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。外耳道清洁，无脓液。鼓膜光反射良好，无充血、穿孔。听力正常。乳突无压痛。,Nose： The nose showed no deformity or flaring of 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 nasolabial grooves were equal bilaterally 鼻： 无畸形或鼻翼扇动。鼻腔无血性或脓性分泌物。鼻甲不肥大。鼻中膈不偏移。副鼻窦无压痛。两侧鼻唇沟对称。,Mounth： The lips were red and moist. No cyanosis. All teeth were present and good. The tongue was thinly coated with normal papillae. No petechiae and no ulcer in the mucosa. No injection on the pharynx. The tonsils were not hypertrophic 口： 口唇红润，无紫绀。牙齿完好。舌苔薄，乳头正常。粘膜无出血点或溃疡。咽不充血，扁桃体不肥大,Neck : Supple. The thyroid was not enlarged. The trachea was in the midline. Flat neck veins. Carotid pulsations were not marked 颈： 软，甲状腺不肿大。气管居中。颈静脉平坦，无明显颈动脉搏动。,Breast : (Man) The breasts were male without masses or discharge. (Female) The breaste were normal female and pendulous, devoid of palpable masses. The nipples showed not discharge and retraction 乳腺： 男：正常男性乳房，无肿块及分泌物。 女：正常女性乳房，悬垂状，未触及肿块。乳头无分泌物，不凹陷。,Chest,Inspection: The PMI ( point of maximum impulse) was in 5th left intercostal space inside of the mid clavicular line and not diffuse Palpation: The PMI was equal to inspection. No thrill 望诊：心尖搏动位于左锁骨中线内侧第5肋间隙，不弥散。触诊：最强搏动点与望诊一致。无震颤。,Chest: Heart,Percussion: The heart percussed normal in size. Picture as follows 叩诊： 心脏浊音界大小正常，如下图所示：,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 murmur 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 bilaterally Percussion: Both lungs were resonant. The right lower limits at the 9th costa and the left at the 10th posteriorly Auscultation: Breath sounds were clear without pathological sounds or rales,Chest: Lung,Inspection： Flat. No scar and no dilated vein seen Palpation: Soft. No tenderness. No palpable masses or organomegaly Percussion: Tympanitic resonance. No shifting dullness Auscultation: Normal bowel sounds ( No increased or decreased bowel sounds),Abdomen,Extremities ( Limbs ): Free movement. No abnormality N. S. : ( Neural system) Physiological reflexes were present without pathological reflexes Genitourinary system: (Man)：Normal adult external genitalia of 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 ping Sex: Male Age: 25ys Race:Han Occupation: worker Married status: married Address: No 2, Feng Yang road, Bengbu Date of admission: March 15th, 1987 Date of record: March 15th, 1987 Offerer of medical history: patient himself Reliability of history: reliable,Basic Information,C.C. (=Cheif complaint): Palpitation, breathlessness and edema for a week P. I. ( = Present illness) : The patient came in this morning with gradually increasing palpitation and dyspnea of a week duration. He cant 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 apparent in the lower limbs.,Arthralgia is often present in the last 10 years, especially in the knees, ankles and shoulder joints when its cold. Antirheumatic therapy (included Aspirin and prednison etc. ) was given for “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 5 years. Infectious history (Contagious history) :He had contact with patient who had pulmonary tuberculosis tor a month about half a year ago. Allergic history :He had no history of allergy to drugs.,Respiratory system: No history of hemoptysis, frequent cough or fever Circulatory system (Cardiovascular system): (He had) no palpitation and edema a year ago Alimentary system (= Digestive system) : No sour regurgitation, stomachache or hematemesis Genitourinary system :No polyuria, urgency of micturition, urodynia or markedly decreased sexual desire (= urge).,Hematopoietic system: There was no history of subcutaneous bleeding or anemia Endocrine system: Drinking and eating were within normal. No tremor or excessive sweating Kinetic system ( Locomotor system of skeletal system): No restriction of the limb movement Neural system: No headache, paralysis or aphasia,Personal history: He has been living here since he was born. Smokes an average of a packet of cigarettes daily for the past 7 years. Didnt drink. He was not exposed to toxic substances in the couse of his work. He got married at the age of eighteen. He has two children Family history: His parents are living and well. There is no hypertension or diabetes in his family. His wife and two children are in good health. Grandfather died from 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 lymph nodes were not palpable,Head：Examinations of the hair, eyes, ears, nose and throat showed no visible abnormality Neck：The neck was supple. No palpable thyroid gland. The trachea was not deviated,Physical Examination,Lungs: Inspection：The chest was flat with normal contour. The respiration was accelerated mildly Palpation：The fremitus was equal without exaggeration or diminution Percussion：The chest was clear to percussion Auscultation：There were no rales,rhonchi, wheezes or rubs present,Physical Exam: Ch