病史书写 PPT课件.ppt

A 一般项目GeneralItems 姓名Name 性别Sex 年龄Age 职业Occupation 民族Race 婚姻状况Maritalstatus 住址Address 病史陈诉者Complainer 可靠性Reliability 入院日期Dateofadmission 记录日期Dateofrecord B 主诉Chiefcomplaint 症状描述 a 好转 减轻 alleviate palliate reduceb 消失 消退 disappear c 加重 恶化 becomeworse aggravated d 无变化 remainthesamee 时好时坏 waneandwax hanginthebalance B 主诉Chiefcomplaint 时间描述 coughwithyellowsputumforfivedaysblacktarrystoolofthreedays durationlowfever2weeksindurationtwo dayhistoryofchestpain 全身症状 General 发热fever疼痛pain不适malaise疲倦lassitude fatigue虚弱weakness debilitating瘦wasting thin emaciation出汗sweating perspiration多汗hidrosis发冷feelchilly畏寒chillysensations寒战shivering shakingchill瘙痒pruritus痒itching A 呼吸系统 气喘asthma咳嗽cough呼吸困难dyspnea咯血hemoptysis喘鸣wheezing痰sputum phlegmB 循环系统 胸痛chestpain心前区痛precordialpain 胸骨后痛retrosternalpain 胸部压榨感 压迫感 窒息感 紧缩感 squeezing pressing choking tightness sensationofthechest泡沫样痰frothysputum活动后气促breathlessnessofexertion阵发性夜间呼吸困难paroxysmalnocturnaldyspnea C 消化系统胃灼热pyrosis腹痛abdominalpain胃痛stomachache厌食anorexia纳差poorappetite恶心nausea呕吐vomiting呕血hematemesis呕粪stercoraceousvomiting呕胆汁biliousvomiting嗳气belching返酸sourregurgitation饭后腹胀postprandialdistension便秘constipation腹泻diarrhea里急后重tenesmus D 泌尿系统 无尿anuria尿浑浊cloudyurine绞痛colic浮肿edema腰痛lumbodynia lumbago夜尿nocturia少尿oliguria多尿polyuria排尿中断interruptionE 造血系统 出血bleeding皮肤出血点bleedingspotsintheskin鼻出血epistaxis牙龈出血gumbleeding术后伤口出血postoperativewoundhemorrhage血尿hematuria F 内分泌系统 贪食hyperorexia矮小dwarfism过高excessiveheight多汗excessivesweating手抖handstremble肥胖obesity消瘦wasting烦渴polydipsia excessivethirstG 生殖系统 月经不调menoxenia月经过多过频epimenorrhagia月经过频epimenorrhea polymenorrhea月经过少hypomenorrhea 指量 oligomenorrhea 间隔长 月经过多menorrhagia 闭经amenorrhea 绝经menostasis menopause H 神经系统 焦虑不安agitation忧虑anxiety失语aphasia健忘amnesia 头晕dizziness倦睡drowsiness蚁走感formication偏身麻木hemianesthesia半身不遂hemiplegia失眠insomnia麻木numbness眩晕vertigo昏倒syncope麻刺感tingling游走痛wanderingpain i 运动系统 关节痛arthrodynia arthralgia背痛backpain腰痛lumbago lurnbodynia足痛footpain肢痛paininlimbs acrodyniaj 皮肤科症状抓痒后渗血bloodoozedoutafterscratchanitch渗出exudation头皮屑scurf肿swollen 耳疾病聋deafness anacousia耳痛otalgia otodynia耳鸣tinnitus头晕vertigo鼻疾病鼻干燥drynessofthenose嗅觉丧失anosmia嗅觉减退hyposmia额部头痛frontalheadache鼻塞nasalobstruction脓鼻涕purulentrhinorrhea鼻出血rhinorrhagia流鼻涕rhinorrhea打喷涕sneezing打鼾snoring水样鼻涕wateryrhinorrhea 咽部疾病咽下困难dysphagia声嘶hoarseness咽食时疼痛painonswallowing咽喉痛sorethroat声音沙哑throatyvoice喘鸣stridorL 眼科视物模糊blurredvision hazyvision复视diplopia闪光flashinglights异物感foreignbodysensation失明losethesight眨眼nictitation眼痛eye ache ocularpain眼花vertigo C 现病Presentillness 起病方式 a 急剧 暴发性 fulminant explosiveb 突然 abrupt suddenc 迅速 rapidd 缓慢 graduale 偶然 accidentally occasionally C 现病Presentillness 发作规律 a 经常反复的 recurrentbouts b 偶尔 sporadicallyc 一过性 transitoryd 持续的 persistente 间歇的 intermittent 疼痛的描述Pain 疼痛的性质 酸痛 achingpain 坠痛 bearing downpain 钻痛 boringpain 烧灼痛 burningpain 撕裂痛 burstingpain 绞痛 colic colicky orcramp griping pain 痉挛性痛 crampingpain 钝痛 dullpain 束带样痛 girdlepain 跳痛 jumpingpain 刀割样痛 knife likepain 刀刺样痛 piercingpain 搏动性痛 throbbingpain疼痛的状态 持续性痛 persistentpain unremittingpain 经常性痛 constantpain 间歇性痛 intermittentpain 阵痛 laborpains 时痛时不痛 Thepaincameandwent 疼痛的描述Pain 疼痛的变化 痛的发生与有关 isassociatedwith痛的减轻 grewless isrelievedby theseveritywaned 疼痛加剧 worsened severe疼痛不停止 didnotcease疼痛持续不变 painwassteady疼痛的位置 疼痛位于部位 limitedto靠近什么部位 near局限于什么部位 localizedorconfinedto转移到 painshiftsto migratesto 痛向什么部位放射 radiatesorrefersto疼痛持续时间 last continue 发热Fever 发热的程度 高热 hyperpyrexia highfever ardentfever低热 slightfever low gradefever subfebriletemperature中度发热 moderatefever 体温变化 升高至 riseto goupto beelevatedto急速降低 fall decline abates drop reduce promptly abruptly 缓慢下降 slowlysis crisis offever不超过 donotexceed goupover 在范围波动 fluctuate vary range between 咳嗽Cough 咳嗽的种类 干咳 dry nonproductive cough阵发性干咳 hackingcough短咳 shortcough剧咳 sharpcough带哮鸣音的咳嗽wheezingcough难咳 distressedcough浅咳 shallowcough刺激性咳嗽 irritablecough痉挛性咳嗽 spasmodiccough接连咳嗽 continuallycoughing阵发性咳嗽 paroxysmalcough痰咳 loosecough湿咳 wet moist cough 痰Sputum 痰的性状 绿痰 aeruginosumsputum aeruginoussputum血痰 bloodysputum恶臭痰 fetid foul sputum粘液脓性痰mucopurulentsputum铁锈色痰 rustysputum浆液痰 seroussputum透明痰 transparentsputum粘痰 viscoussputum 大便Stool 大便的性状 无胆色粪 acholicstool胆汁粪 biliousstool干便 drystool稀便 loosestool不成形便 formlessstool黑粪 melena豆浆样便 pea soupstool米泔样便 rice waterstool柏油样便 tarrystool不消化粪 undigestedstool稀水便 watery liquid stool 大便Stool 大便的气味 恶臭 stench臭的 foul fetid非常臭 extremelyfoul不太臭 lessoffensiveinodor无臭的 odorless味道难闻但不太臭的 offensivebutnotexcessivelyfoul腐败臭的 putrid酸臭的 sour 大便Stool 大便的颜色 黑色 black血性 bloody棕色 brown棕黑色 brownishblack绿色 green灰白色 grey white柏油色 tarry黄色 yellow泥土色 clay colored 小便Urine 小便的透明度 澄清的 clear混浊的 cloudy不透明的 opaque透明的 transparent半透明的 translucent 小便Urine 小便的颜色 黑色 black棕黑色 brown dark鲜红色 brightred红色 red深棕色 dark brown暗蓝色 dirtyblue乳白色 milky橙黄色 orange棕黄色 brownyellow 体格检查 一般资料GeneralCondition 体温 a 口温 permouth oraltemperature b 腋温 peraxilla axillarytemperaturec 肛温 perrectum rectaltemperaturea热型 a 稽留热 continuousorsustainedb 周期性 periodicc 弛张型 remittentormalarial 一般资料GeneralCondition 脉搏种类 速脉 fastorrapid徐脉 slow重脉 dicroticpulse不规则脉 irregularpulse奇脉 paradoxicalpulse水冲脉 water hammerpulse间歇脉 intermittentordropped beat 一般资料GeneralCondition 呼吸描述 气促 tachypnea 呼吸困难 dyspnea费力 laborious labored端坐呼吸 orthopnea张口呼吸 buccalbreathing不能察觉 imperceptible 一般资料GeneralCondition 呼吸类型 腹式呼吸 abdominalrespiration深吸气性呼吸 apneusticrespiration周期性呼吸 periodicrespiration鼾声呼吸 stertorousrespiration叹息样呼吸 sighingrespiration 一般资料GeneralCondition 呼气的气味 口臭 foulbreath恶臭气息 fetidbreath呼气口臭 offensivebreath甜而酸败的气味 asweetishmustyodorofthebreath强烈酮味 astrongsmellofketone呼气丙酮味 anacetoneodoronbreath Theexaminationrevealednodyspneaatrestwithrespiratoryrateof20 min 2 Thepatientbecameextremelydyspnea 3 Thereisfetorhepaticus ieasweet mustyodorofthebreath 一般资料GeneralCondition 体位 被动体位 passiveposition强迫体位 forcedposition平卧位 recliningposition horizontal recumbent 仰卧位 supineposition侧卧位 lateral decubitus position 特殊体位 蜷腿位 coiledposition膀胱截石位 dorsosacralposition胸膝位 knee chestposition膝肘位 knee elbowposition角弓反张位 opisthotonosposition端坐呼吸位 orthopneaposition偏侧卧位 unilateralposition 一般资料GeneralCondition 神志 意识 清醒的 alert conscious lucid半清醒的 semi conscious昏迷的 comatose半昏迷的 semicomatose木僵的 stuporous淡漠的 lethargic嗜睡的 drowsy sleepy忧虑的 anxious 一般资料GeneralCondition Hewasconsciousandcooperative andcouldanswerallquestions 2 Thepatienthadadull expressionlesslethargicface3 Hewasinsemicomatosstate reactingonlytopainfulstimuli 面容不安面容 anxiousexpression痛苦表情 distressingexpression颜面潮红 flushingoftheface reddyface二尖瓣面容 mitralface 满月脸 moonface不适表情 pinchedexpression 一般资料GeneralCondition 发育身高 heightofthebody身材 stature体格 build physique巨人 giant运动员体型 athletictype矮胖体型 stockytype 一般资料GeneralCondition 营养营养良好 well nourished营养中等 middle nourished营养不良 ill mal under nourished肥胖 fat obese overweightgiant消瘦 thin lean marasmus恶病质 cachexia 一般资料GeneralCondition Thepatientexhibits mitralfaces 2 Helooks orappears acutelyill Hewasinacutedistress3 Heisastockybuild 4 Physicalexaminationshowedastrikingwastingofthearmsandlegsascomparedtotherestofthebody 皮肤 粘膜颜色色素减退 depigmentation雀斑 fleck潮红 flush面色红润 floridfacies色素沉着过多 hyperpigmentation黄疸 jaundice icterus icteric 苍白 pallor paleness紫纹 purplestriae 一般资料GeneralCondition 皮肤 粘膜外观紫绀 cyanosis干燥 dry湿润 moist四肢湿冷 coldmoistextremities温暖的 warm光滑的 glossy粗糙的 harsh rough鳞状的 scaly 一般资料GeneralCondition 皮损斑疹 macule斑块 plaque斑丘疹macule papule丘疹 papule玫瑰疹 rosespots疱疹 blebs脓疱 pusblister pustule血疱 bloodblister寻麻疹 hivesurticaria 一般资料GeneralCondition 皮损囊肿 cyst疤痕 scar皮屑 furfur结痂 crust溃疡 ulcer皲裂 fissure肝掌 liverpalms蜘蛛痣 vascularspiders 一般资料GeneralCondition Pallorappearsuponelevationoftherightfoot2 Thelips mucousmembranes andnailbedsaremarkedly moderately faintly cyanotic3 Somespiderneviareseenovertheupperthoraxandshulders 出血征瘀点 petechia紫斑 purpura瘀斑 ecchymosis血肿 hematoma片状出血 splinterhemorrhage渗血 oozingoftheblood 一般资料GeneralCondition 毛发粗的 coarse细的 fine无光泽的 lusterless毛发干燥 trichoxerosis稀少的 sparse毛发稀少 oligotrichosis 一般资料GeneralCondition 浅表淋巴结耳后 postauricular 枕部的 occipital颈部的 cervical锁骨上的 supraclavicular腋窝的 axillary腹股沟的 inguinal 一般资料GeneralCondition Therearemuchsmall redspotswith1to2mmindiameteranddon tblanchonpressureonhisbody2 Thehairarefine dryandbrittle3 Thereare2movable non tender notparticularlyfirmlymphnodesintherightaxillaryregion 外形头围 headcircumference头颅骨缝 cranialsuture囟门膨出 凹陷 bulging depressed fontanel长头 dolichocephalism短头 brachycephalism尖头 acrocephalia小头 microcephalism B 头部 Cranium 眼右眼 oculusdexter OD 左眼 oculussinister OS 眼球凹陷 sunkeneyes enophthalmos眼球突出 ocularproptosis protrudingeyes exophthalmos眼球震颤 nystagmus B 眼 Eye 眼睑 eyelid 上睑下垂 ptosis眼睑痉挛 blepharospasm睑痉挛 blepharoptosis睑颤动 flickeringlid兔眼 lagophthalmos常闪目 frequentblinking流泪 lacrimation B 眼 Eye 结膜 conjunctiva 苍白 pallor充血 congestion滤泡 follicle球结膜水肿 chemosis水样 脓性 分泌物 watery purulent discharge B 眼 Eye 角膜 cornea 苍白 pallor透明的 transparent浑浊的 opaque穿孔 perforation异物 foreignbody溃疡 ulcer老年环 arcussenilis角膜浸润 corneainfiltration B 眼 Eye 瞳孔 pupil 瞳孔缩小 contractionofpupils瞳孔缩小 dilationofpupils瞳孔大小不一 unevenessofpupils瞳孔对光反射 lightreflexofpupils B 眼 Eye 1 Theheadisnormocephalic Theshapeofhisheadisnormal Hisheadisnormalinconfiguration Hehasanormal shapedhead2 Thehairarefine dryandbrittle3 Thereare2movable non tender notparticularlyfirmlymphnodesintherightaxillaryregion Scleraeareclearandanicteric2 Cornealreflexesaregood3 Thepupilsareunequalandreactpoorlytolight4 ThepupilsshrinktoaslittleasImmindiameter butretaintheirlightreflexes B 眼Eye 视野VisualField 完整的 Full lntact偏盲 hemianopia单侧缺损 unilateraldefects双颞侧缺损 bitemporaldetectsThevisualfieldsarefull Thereishemianopiaoftheleftside B 眼Eye 眼底Fundus 动脉狭窄 arteriolarnarrowing动静脉压迹 AVnicking微小动脉瘤 microaneurysm火焰样出血 flamehemorrhage点状出血 punctatehemorrhage视神经乳头水肿 papilledemaTheretinalveinsbecomeengorged Thereareretinalhemorrhagesandpapilledema B 眼Eye 视力Vision 视力模糊 blurredvision eye blurred视力减退 impairedvision poorvision失明 amaurosis弱视 amblyopia手动 handmovernent光感 lightperception数指 countingfinger视觉敏锐 oxyopia复视 doublevision斜视 cross eye squint strabismus B 眼Eye 视力Vision 近视 myopia myopy远视 hyperopia hypermetropiaThevisionofthelefteyeis0 2Short sighted Far sighted 200degree OD 175degree OS B 眼Eye 色觉colorperception 视力模糊 blurredvision eye blurred色盲 chromatodysopia全色盲 achromatopsia绿色盲 achloropsia greenblindness蓝色盲 acyanoblepsia色弱 colorweakness红绿盲 red greenblindness anerythrochloropsia B 眼Eye 色觉colorperception HehasredandgreencolorblindnessHehasacolorweaknessTheintraocularpressure 30mmHg OD 20mmHg OS C 耳Ear 鼓膜drum tympanicmembrane 视力模糊 blurredvision eye blurred膨出 Bulge发红的 flushed内陷 Indrawing穿孔 perforation中央性穿孔 centralperforation边缘性穿孔 marginalperforation C 耳Ear 听力hearing 听觉迟顿 amblyacousia baryacusia听觉减退 hearingloss传导性耳聋 conductivedeafnessHecouldhearconversationalVoiceonlywithinadistanceofameterontherightside Hearingtestsconfirmthepresenceofconductivedeafness D 鼻Nose 1 Theexaminationrevealsasaddledeformityofthenose2 Thereisashallowulcer l 5by1cm witharaisedborderonthenasalapex3 Themucosaandturbinatesarewithinnormallimits D 鼻Nose 4 Thenasalmucasaisredandswollen andthecavitycontainswaterysecretion5 Rhinoscopyshowsapinkishsoftfriablemass whichbleedseasilyontouch arisingfromthemiddlemeatusoftheleftnose6 Posteriorrhinoscopyshowsasmooth greyish white sphericalmassinthechoana D 鼻Nose 嗅觉Smell Scent 嗅觉缺失 anosmia嗅觉迟顿 baryodmia嗅觉敏锐 oxyosphresiaAnteriorrhinoscopyrevealstheseptumismarkedly acutely deviatedtotheleft Posteriorrhinoscopyshowsmucopusonthesuperiorsurfaceofthesoftpalate Thereistendernessoverthefrontalsinuses E 口腔与咽Mouthandpharynx 粘膜与口唇Smell Scent 唇干裂 Cheilosis口臭 halitosis口唇疱疹 herpeslabialsSomewhiteplaquesareontheoralmucosa theplaqueisscrapedoffwithdifficulty exposingaredbase E 口腔与咽Mouthandpharynx 牙齿tooth 牙齿磨损 attritionofthetooth龋齿 dentalcaries decayedteeth假牙 falseteeth镶牙 insertteeth牙齿松动 looseningofthetooth牙齿脱落 loseatooth牙髓炎 pulpitis牙石 tartar dentalcalculus 牙关紧闭 trismus clenchingoftheteethHis2ndmolarisdecayedtooth E 口腔与咽Mouthandpharynx 舌tongue 舌苔 coatedtongue furredtongue地图舌 geographictongue舌面光滑 smoothtongue草莓舌 strawberrytongue1 Thetongueismoistandwellpapillatedwithnocoating2 Creamy whiteplaquesarefoundonthetongue E 口腔与咽Mouthandpharynx 咽和扁桃体pharynxandtonsil 1 Thereisnoenlargedtonsils andnoinjectionandexudateonthepharynx2 Thelymphoidfolliclesontheposteriorpharyngealwallareobviousasdiscretenodules3 Thetonsilsarecongested swollenandstuddedwithyellowbeadsofpus E 口腔与咽Mouthandpharynx 喉larynx 失声 aphonia lossofvoice尸位 cadavericposition哑dumbness mutism声嘶 hoarseness变音 mutationofvoice 喉larynx 1 Hisvoiceispeculiarandlikesaduet2 Atlaryngoscopytherearebunchesofwart likeexcrescencesofthelarynx pinkish whiteincolor3 Vocalcordsareedematousandpusisseenintheinterarytenoidregionandaroundtheepiglottis4 Indirectlaryngoscopyshowstheleftvocalcordinparamedianposition E 口腔与咽Mouthandpharynx 角弓反张 opisthotonos软的 supple颈强直 stiff neck nuchalrigidity 静脉 怒张 distentionandprominence平坦 flat充盈 full engorged肝颈静脉反流 hepatojugularreflex震颤 thrill甲状腺肿大 goiter enlargedthyroid气管偏移 trachealdeviation F 颈部Neck 1 Thebreastsarenormalfemalewithoutmassesordischarge2 Thereareslightnippleretractionandbloodydischargefromthenippleoftherightbreaat3 Anontender firmlumpwith2by3cmindiameterinpalpatedintheupperouterquadrantoftheleftbreast 四 胸部Chest 4 Thechestdemonstratedalipomaontherightanteriorchestwall5 Thepatienthadalacerationpresentattheleft8thintercostalspace 6 Thereisnoabnormalityoftheribs 四 胸部Chest 肺lung Inspection 胸腔前后径 anteroposteriordiameterofthechest端坐呼吸 orthopnea三凹征 depressionofthreefossae retractionsign 桶状胸 barrelchest鸡胸 chichen orpigeon chest漏斗胸 funnelchest佝偻病胸 rachiticchest 四 胸部Chest 肺lung Palpation 触觉性震颤 tactilefremitus胸膜摩擦 pleuralfrictionalfeeling语音震颤 vocalfremitus1 Thefremitusisequalbilaterally2 Thetactilefremitusisdiminishedattherightbase 肺lung Percussion 浊音 dullness实音 flatness过度反响 hyperresonance清音 vesicular鼓音 tympany tympaniticresonance1 Bothlungsareresonanttopercussion2 Thechestshowsincreasedresonancetopercussionovertheleftside3 Dullnesstopercussionappearsinleftlung 肺lung Auscultation 支气管音 bronchophony支气管肺泡音 bronchovesicularsounds空洞语音 caverniloquy粗大罗音 coarse medium fine rale捻发音 crepitantrales支气管语音 egophony吸气末细湿罗音 fineend inspiratoryrales湿罗音 moist bubbling rales胸膜摩擦音 pleuralfrictionrub咳嗽后 post tussive鼾音 rhonchi sonorousrales粗糙呼吸音 roughbreathsound 肺lung Auscultation 哮鸣音 wheezes wheezing飞箭音 sibilantrales管状 支气管 呼吸音 tubular bronchial breathsounds肺泡呼吸音 vesicularbreathsounds整个肺野 entire orwhole lungfield右上肺 therightupperlung中前胸部 themiddleofthechestanteriorly左肺上1 3处 theupperone thirdoftheleftchest 肺lung Auscultation 1 Diminished exaggerated breathsoundsonauscultationappearintherightupperlung2 Therearetubularbreathsoundsovertheleftlowerlung3 Therearelargemoistralesintherightbetweenthe4thand8thribsanreriorly4 Scatteredhighpitchedrhonchioverbothlungfields 心脏heart Inspection 隆起 bulge heave弥散的 diffuse肋间隙 ICS intercostalspace锁骨中线 MCL midcalvicularline最强搏动点 PMI pointofmaximumimpulse心尖搏动 apicalimpulse apexbeat震颤 systolic diatolicthrill 四 胸部Chest 心脏heart Palpation 1 Theapexbeatcanbefeltinthe5thinterspace1cminsidetheleftmammilaryline2 Apexbeatisforcefulandenlarged3 Apicalimpulseisdifficulttofeel4 Apicalimpulsedisplacedsignificantlytotheleftanddown5 Systolicthrillispalpatedatthesecondintercostalspaceofleftsternalborder 心脏heart Percussion 心脏绝对 相对 浊音界 Absolute relative cardiac dullness 1 Theheartsizeisnormalonpercussion2 Cardiacdullnesstopercussionisdiminished3 Percussion enlargedontheleftside extendingtotheanterioraxillaryline4 LeftabsolutecardiacduUnessislocated1 5cmtotheleftofthemidclavicularline 心脏heart Auscultation 心音 cardiacsounds生理性分裂 physiologicsplitting二尖瓣第一 二 音 M1 M2 mitralfirst