资源描述
一般检查general examination
一, 性别sex 男Male 女Female
二, 年龄 age
三, 生命体征 :vital age体温body temperature
a,口测法oral measurement b,肛测法archos measurement c,腋测法axil measurement呼吸respirations脉搏pulse血压 blood pressure
四,发育development
体型(Habitus):无力型(asthenic type)、超力型(sthenic type)、正力型(orthosthenic type)
五,营养state of nutrition: 良好well、中等moderatelty。肥胖(Obesity)、消瘦slake
六,意识consciousness: 嗜睡drowsiness、意识模糊clouding of consciousness 昏睡hyponody、昏迷coma(浅,中,深度),谵妄acute confusional state
七,语调tone 语态voice
八,面容facial features
急性病容face of acute ill,慢性病容chronic disease face,贫血面容anemic face,甲亢面容hyperthyreosis feature,粘液性水肿面容myxedema face, 二尖瓣面容mitral facies,满月脸面容moon face,肢端肥大症面容acromegaly facies,伤寒面容typhoid face,病危面容,Hippocrates face
表情expression 正常normal,淡漠indifference烦躁不安dysphoria,痛苦suffering 忧郁gloom
九,体位position
a,自主体位active position b,被动体位passive position 极度意识衰竭和丧失culmination consciousness failure and loss
c,强迫体位compulsive position 强迫坐位(端坐呼吸)compulsive sitting position (orthopnea)
十,姿势posture
十一,步态 gaita
a,蹒跚步态 waddling gait b,醉酒步态drinken man gait c,共济失调步态 ataxic gait d,慌张步态 festinating gait e,跨閱步态 steppage gait f,剪刀步态 scissor gait g,间歇性跛行 intermittent gait
十二,皮肤skin
1, 颜色skin color a,苍白 pallor 贫血anaemia b,发红 redness 发热fever c,发绀 cyanosis 缺氧 hypoxia d,黄染 stained yellow 肝病liver disease e,色素沉着 pigmentation 肝病liver disease f,色素脱失 coloring material loss 白化症 albinismus
2,湿度moisture 干燥dry 脱水dewat 湿润moist 休克shock 3,弹性elasticity
4,皮疹skin eruption a 斑疹 maculate b 玫瑰疹roseola c 丘疹papules ; d 斑丘疹maculopapulate , e 荨麻疹urticaria
5,脱屑scales 6赘生物vegetation 7,皮下出血subcutaneous hemorrhage
a 瘀点petechia b瘀斑ecchymosis c 紫癜purpura d血肿hematome
8,蜘蛛痣 spider angioma 肝掌liver palms 9,水肿edema 10,皮下结节subcutaneous nodules 11,瘢痕scar 12,毛发hair 13,淋巴lymph
体检(胸腹部)[Physical examination(chest and belly)]
1、肋骨和软组织[ribs and soft tissure]
·胸骨上切迹[suprasternal notch]
·浮肋[free ribs]
·胸壁[chest wall]
·扁平(桶状、佝偻、漏头、鸡)胸[flat (barrel,rachitic, funnel, pigeon) chest]
·皮下气肿[subcutaneous emphysema]
·捻发音[Crepitus]
·软组织损伤[soft tissue injury]
·肋骨畸形[abnormality of the ribs(rib deformity, costal anomaly)]
·肋软骨畸形[costochondral deformity]
·肋软骨增生[costal cartilage hyperplasia]
·肋下切口[subcostal incision]
·肋间隙宽(窄)[wide (narrow) intercostal space]
2、乳房[breast]
3、肺[lung]
·呼吸缓慢(急促)[bradypnea (tachypnea)]
·呼吸浅慢(深快)[hypopnea (hyperpnea)]
·呼吸不规则[irregular respiration]
·点头呼吸[nodding breathing]
·端坐呼吸[orthopnea]
·三凹征[retraction sign of three fossae]
·叹息样呼吸[sighing respiration]
·浅快[shallow and rapid]
·呼(吸)气性呼吸困难[expiratory (inspiratory) dyspnea]
·呼吸道烧伤(塌陷)[burn (collapse) of respiratory tract(airway)]
·呼吸道阻塞[respiratory tract obstruction]
·呼吸均匀(呼吸加深或加快)[eupnea(exaggerated or acclerated respiratory)]
·呼吸停止[apnea]
·呼吸费力[respiration is labored]
·语音(触觉)震颤[vocal (tactile) fremitus]
·语颤相等(减弱、增强)[vocal fremitus is equal(diminished, accentuated)]
·间接(直接)叩诊[mediate (immediate) percussion]
· 浊(实、鼓、清、过清、金属)音[dullness (flatness, tympany, vesicular resonance, hyperresonance, bell)]
·移动范围[range of movement]
· 呼吸音消失(减弱,增强)[absence (diminution, exaggeration) of breath sound]
·呼吸音粗(清)[sound of breath(SOB) is rough (clear)]
·支气管(支气管肺泡,肺泡)音[bronchophony (bronchovesicular sound, vesicular sound)]
·管状呼吸音[tubular breath sound]
·捻发音[crepitant rales]
·爆裂音[crackles]
·干(湿)罗音[dry (moist) rales]
·细(中等、粗)罗音[fine (medium, coarse) rales]
·呼(吸)气未罗音[end-inspiratory (expiratory) rales]
·胸膜摩擦音[pleural friction rub]
·呼(吸)气延长[prolonged inspiratory (expiratory)]
·高(低)调鼾音[sibilant (sonorous) rhonchi (sonorous rales)]
·哨笛音[sibilant rales]
·哮鸣音[wheezing]
·小(中、大)水泡音[small(middle, big) bubbles]
·支气管语音[bronchophony]
·耳语音[whispered]
·羊鸣音[egophony]
·高(低)音调[high (low)-pitched]
·两肺部(右背部)[over both lung fields (right back)]
·两(左)肺底[over the both (left) lower lung]
·整个肺野[the whole lung field]
·左(右)上(下)肺[the left (right) upper (lower) lung]
·肺尖(底)[apex (base) of lung]
4、心脏[Heart]
心房atrium cordis 心室cardiac ventricle 室间隔interventricular septum 房间隔atrial septum 主动脉瓣aortic valve 肺动脉瓣pulmonary valve 二尖瓣atrioventricular valve,left 三尖瓣atrioventricular valve,right;
·用手掌(指尖)触诊心尖搏动[palpate apical area with palm numbness (fingertips)]
·心前区隆起(凹陷)[precordial bulge (retraction)]
·搏动弥漫(局限)[diffuse (local) pulsation]
·负性搏动[inward inpulse]
·心尖搏动[apex beat (apical impulse)]
·剑突下搏动[xiphoideusal pulsaton]
·抬举性心尖搏动[heaving apex impulse]
·心尖搏动最强点[point of maximal impulse (PMI)]
·锁骨中线[mid-calvicular line (MCL)]
·肋间[intercostal space (ICS)]
·收缩(舒张)期震颤[systolic (diastolic) thrill]
·心浊音界[the border of cardiac dullnes]
·心绝对(相对)浊音界扩大(缩小)[enlarged (diminished) absolute (relative) cardiac dullness]
·叩诊心脏大小正常[heart size is normal on (to) percussion]
·心脏向左(右)扩大[cardiac dilation (enlargement) to the left (right)]
·第1(2、3、4)心音[S1(S2,S3,S4)]
·第1心音增强(减弱,听不清)[first heart sound is exaggerate (decreased, muffled)]
·生(病)理性杂音(分裂)[physiologic (pathological) murmur (splitting)]
·生理性(固定、反常、逆)分裂[physiologic (fixed, paradoxical, reversed) splitting]
·肺动脉瓣第2心音>(=,<)主动脉瓣第2心音[P2>(=,<)A2]
·大炮音[connon sound]
·心音消失[heart sound is absent (disapeared)]
·心音增强(减弱)[accentuated (diminished) cardiac sound]
·心音响亮(遥远)[cardiac sound is loud (distant)]
·收缩期(舒张期,连续性)杂音[systolic (diastolic, continuous) murmur]
·收缩(舒张)前(中、晚)期杂音[pre-(mid-, post) systolic (diastolic) murmur]
·全收缩期的[holosystolic(pansystolic)]
·全舒张期的[holodiastolic (pandiastolic)]
·低(高)音调[low (high) pitched]
·递减(递增,递减-递增)性杂音[decrescendo (crescendo, decrescendo-crescendo)murmur]
·呈喷射型[be ejection in type]
·Ⅳ级喷射型收缩期杂音[grade Ⅳ(I-Ⅳ/6) systolic ejection murmur]
·吹风样杂音[murmur of puffing character]
·低音调隆隆样[low-pitched rumbling quality]
·柔和(粗糙)的[soft (harsh or rough)]
·吹风样(喷射性、隆隆样、沙沙声样、搔抓声样、机器声样、汽笛声样、倒水声样)杂音[blowing (ejection, rumbling, rustting, scratching, machinary, whistling, pouring )murmur]
·功能性(器质性)杂音[functional (organic) murmur]
·血管(静脉)杂音[vascular (venous) murmur]
·枪击音[pistol shot sound]
·静脉营营音[venous hum]
·奔马律[gallop rhythm]
·胎心律[embryocardia]
·心律齐(不齐)[regular (irregular) rhythm]
·心律不齐[arrhythmia]
·二(三)联律[bigeminy (trigeminy)]
·早搏[premature (extrasystol)]
·喀嗽音[click]
·钟摆律[pendular rhythm]
·二尖瓣开瓣音[mitral opening snap]
·心包摩擦音[pericardial friction sound]
·听诊[on auscultation]
·二尖瓣(主瓣,肺瓣,三尖瓣)听诊区[mitral (aortic, pulmonary, tricuspid) valve area]
·心包叩击音[pericardial knock]
·肿瘤扑落音[tumor plop]
5、腹部[abdomen]
·腹膨隆[abdominal distention (prominence)]
·腹平坦(凹陷)[abdominal flatness (retraction)]
·蛙状(球状、舟状)腹[frog(bulbous, scaphoid) belly (abdomen)]
·腹围增大[increased abdominal girth]
·肠型[intestinal pattern]
·胃(小肠)蠕动波[gastric (intestinal) peristaltic wave]
·静脉曲张[varicosity (dilated tortuous vein)]
·疤痕[scar]
·腹壁紧张(松驰)[guarding (abdominal muscular relaxation)]
·腹壁切口(创伤)[incision (wound) of abdominal wall]
·腹部分区[abdominal region]
·左(右)上(下)腹[left (right) upper (lower) quadrant]
·脐膨出[projection of the umbilicus]
·腹式呼吸[abdominal (diaphragmatic) breathing]
·腹壁松弛[lax abdominal wall]
·肝肿大[hepatomegaly (enlargement of the liver)]
·脾肿大[splenomegaly (enlargement of the spleen)]
·右肋下5厘米[5 cm below the right costal margin]
·肿块(肝)质硬[firm mass (liver)]
·莫菲氏征[murphy`s sigh]
·肌卫现象[muscle guarding (tension)]
·反跳痛[rebound tenderness]
·压痛点[tenderness point]
·剑突下压痛[tenderness beneath the xiphoid process]
·麦氏点压痛[McBurney`s point tenderness]
·腹肌强直(板状腹,板样强直)[rigor of abdominal muscle (wooden belly, board-like rigidity)]
·柔韧感[dough kneeding sensation]
·波动感[fluctuation]
·腹股沟疝[inguinofemoral hernia]
·腹壁反射[abdominal reflex]
·腹水征[sign of ascites]
·膀胱肿大[bladder expansion]
·膀胱区(脊肋角)压痛[tenderness of bladder region (costovertebral angle)]
·肾(肝)区叩击病[percussion tenderness on kidney (liver) region]
·移动性浊音[shifting dullness]
·鼓音[tympany(tampanitic resonance)]
·肝(脾)浊音区[hepatic (splenic)dullness area]
·肠鸣音正常(亢进、减弱、消失)[normal (hyperactive, diminished, absent) bowel sound]
·气过水声[gurgling]
·振水声[succusion (splashing) sound]
2、常见症状
· [Fever] 发热
· [Pain] 疼痛
· [Edema] 水肿
· [Mucocutaneous hemorrhage (bleeding)] 皮肤粘膜出血
· [Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困难
· [Cough and expectoration (Sputum;Phlegm)] 咳嗽和咯痰
· [Hemoptysis] 咯血
· [Cyanosis] 紫绀
· [Palpitation] 心悸
· [Chest discomfort] 胸闷
· [Nausea (Retch;Dry Vomiting)and Vomiting] 恶心和呕吐
· [Hematemesis (Vomiting of blood)] 呕血
· [Hematochezia (Hemafecia)] 便血
· [Diarrhea] 腹泻
· [Constipation (Obstipation)] 便秘
· [Vertigo (Giddiness; Dizziness)] 眩晕
· [Jaundice (Icterus)] 黄疸
· [Convulsion] 惊厥
· [Disturbance of consciousness] 意识障碍
· [Hematuria] 血尿
· [Frequent micturition,urgent micturition and dysuria] 尿频,尿急和尿痛
· [Incontinence of urine] 尿失禁
· [Retention of urine] 尿潴留
(1)发热的表示方法
· [Infective (Septic)fever] 感染性发热
· [Non-infective (Aseptic)fever] 非感染性发热
· [Dehydration (Inanition)fever] 脱水热
· [Drug fever] 药物热
· [Functional hypothermia] 功能性低热
· [Absorption fever] 吸收热
· [Central fever] 中枢性发热
· [Fever type] 热型
▲ [Continuous fever] 稽留热
▲ [Remittent fever] 驰张热
▲ [Intermittent fever] 间歇热
▲ [Undulant fever] 波状热
▲ [Recurrent fever] 回归热
▲ [Periodic fever] 周期热
▲ [Irregular fever] 不规则热
▲ [Ephemeral fever] 短暂热
▲ [Double peaked fever] 双峰热
· [Fever of undetermined(unknown) origin, FUO] 不明原因发热
· [Rigor (shivering;chill;shaking chill;ague)] 寒战
· [Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒
· [Ultra-hyperpyrexia] 超高热
· [Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高热
· [Moderate fever] 中度发热
· [Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低热
· [Become feverish (Have a temperature)] 发热
· [Crisis] 骤降
· [Lysis] 渐降
· [Rheumatic fever] 风湿热
· [Cancerous fever] 癌性发热
· [Fervescence period] 升热期
· [Defervescence period] 退热期
· [Persistent febrile period] 持续发热期
(2)疼痛的表示方法
· [Backache (Back pain)] 背痛
· [Lumbago] 腰痛
· [Headache] 头痛
▲ [Vasomotor headache] 血管舒缩性头痛
[Migraine headache] 偏头痛
· [Chest pain] 胸痛
· [Precardial pain] 心前区痛
· [Retrosternal pain] 胸骨后痛
· [Abdominal pain (Stomachache)] 腹痛
· [Acrodynia (pain in limbs)] 肢体痛
· [Arthrodynia (Arthralgia)] 关节痛
· [Dull pain] 钝痛
· [Sharp pain] 锐痛
· [Twinge pain] 刺痛
· [Knife-like pain (Piercing pain)] 刀割(刺)样痛
· [Aching pain] 酸痛
· [Burning pain] 烧灼痛
· [Colicky (Griping;cramp) pain] 绞痛
· [Colic] 绞痛
· [Bursting pain] 胀痛(撕裂痛)
· [Hunger pain] 饥饿痛
· [Tic pain] 抽搐痛
· [Bearing-down pain] 坠痛
· [Shock-like pain] 电击样痛
· [Jumping pain] 反跳痛
· [Tenderness pain] 触痛(压痛)
· [Girdle-like pain] 束带样痛
· [Wandering pain] 游走性痛
· [Throbbing pain] 搏动性痛
· [Radiating pain] 放射性痛
· [Cramping pain] 痉挛性痛
· [Boring pain] 钻痛
· [Intense pain] 剧痛
· [Dragging pain] 牵引痛
· [Labor pain] 阵痛
· [Cancerous pain] 癌性疼痛
· [Referred pain] 牵涉痛
· [Persistent pain (Unremitting pain)] 持续性痛
· [Constant pain] 经常性痛
· [Intermittent pain] 间歇性痛
(3)水肿的表示方法
· [Mucous edema (Myxedema)] 粘液性水肿
· [Cardiac (Cardiogenic) edema] 心源性水肿
· [Nephrotic (renal) edema] 肾源性水肿
· [Hepatic edema] 肝源性水肿
· [Alimentary (Nutritional) edema] 营养不良性水肿
· [Angioneurotic edema] 血管神经性水肿
· [Pitting] 凹陷性
· [Nonpitting] 非凹陷性
· [Localized (Local) edema] 局限性水肿
· [Generalized edema (Anasarca)] 全身性水肿
· [Hydrops] 积水
· [Cerebral(Brain) edema] 脑水肿
· [Pulmonary edema (Hydropneumonia0] 肺水肿
· [Hydrocephalus] 脑积水
· [Invisible (Recessive) edema] 隐性水肿
· [Frank edema] 显性水肿
· [Inflammatory edema] 炎性水肿
· [Idiopathic edema] 特发性水肿
· [Cyclical edema] 周期性水肿
· [Ascites (Abdominal effusion;hydroperiotoneum)] 腹水
· [Pleural effusion (Hydrothorax)] 胸水
· [Pericardial effusion (Hydropericardium)] 心包积液
· [Bronchoedema] 支气管水肿
· [Slight (Mild)] 轻度
· [Moderate] 中度
· [Serious] 重度
· [Transudate] 漏出液
· [Exudate] 渗出液
(4)呼吸困难的表示方法
· [Cardiac dyspnea] 心原性呼吸困难
· [Inspiratory] 吸气性
· [Expiratory] 呼气性
· [Mixed] 混合性
· [Obstructive] 梗阻性
· [Dyspnea at rest] 静息时呼吸困难
· [Dyspnea on exertion] 活动时呼吸困难
· [Dyspnea on lying down] 躺下时呼吸困难
· [Paroxysmal nocturnal dyspnea,PND] 夜间阵发性呼吸困难
· [Orthopnea] 端坐呼吸
· [Asthma] 哮喘
· [Cardiac asthma] 心源性哮喘
· [Bronchial asthma] 支气管性哮喘
· [Hyperpnea] 呼吸深快
· [Periodic breathing] 周期性呼吸
· [Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)]气促
· [Bradypnea (Slow breathing)] 呼吸缓慢
· [Irregular breathing] 不规则呼吸
(5)皮肤粘膜出血的表示方法
· [Bleeding spots in the skin] 皮肤出血点
· [Petechia] 瘀点
· [Eccymosis] 瘀斑
· [Purpura] 紫癜
· [Splinter hemorrhage] 片状出血
· [Oozing of the blood (Errhysis)] 渗血
· [Hemorrhinia (Nasal bleeding)] 鼻衄
· [Ecchymoma] 皮下血肿
(6)咳嗽与咯痰的表示方法
· [Dry cough (Nonproductive cough;hacking cough)] 干咳
· [Sharp cough] 剧咳
· [Wet cough (Moist cough)] 湿咳
· [Productive cough (Loose cough)] 排痰性咳
· [Chronic cough] 慢性咳嗽
· [Irritable cough] 刺激性咳嗽
· [Paroxysmal cough] 发作性(阵发性)咳嗽
· [Cough continually] 持续性咳嗽
· [Spasmodic cough] 痉挛性咳嗽
· [Whooping cough] 百日咳
· [Wheezing cough] 喘咳
· [Droplet] 飞沫
· [Frothy sputum] 泡沫样痰
· [Bloody sputum] 血痰
· [Mucous (Mucoid) sputum] 粘液样痰
· [Purulent sputum] 脓痰
· [Mucopurulent sputum] 粘液脓性痰
· [White (Yellow,green) sputum] 白(黄,绿)痰
· [Fetid (Foul) sputum] 恶臭痰
· [Iron-rust (Rusty) sputum] 铁锈色痰
· [Chocolate coloured sputum] 巧克力色痰
· [Thick sputum] 浓痰
· [Thin sputum] 淡痰
· [Viscous sputum] 粘痰
· [Transparent sputum] 透明痰
· [Much (Large amounts of) sputum] 大量痰
· [Moderate amounts of sputum] 中等量痰
· [Not much (Small amounts of ) sputum] 少量痰
(7)内脏出血的表示方法
· [Massive hematemesis]大量呕血
· [Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)]鼻衄
· [Hematuria] 血尿
· [Initial hematuria] 初血尿
· [Idiopathic hematuria] 特发性血尿
· [Painless hematuria] 无痛性血尿
· [Terminal hematuria] 终末性血尿
· [Gross (Macroscopic) hematuria] 肉眼血尿
· [Microscopic hematuria] 镜下血尿
· [Hematuria in the whole process of urination] 全程血尿
· [Gingival bleeding (Ulaemorrhagia;gum bleeding)] 牙龈出血
· [Hematochezia] 便血
· [Bloody stool] 血便
· [Black stool (Melena)] 黑便
· [Tarry stool] 柏油样便
· [Occult blood,OB] 隐血
· [Hemathorax] 血胸
· [Hematocoelia] 腹腔积血
· [Hematoma] 血肿
· [Hemopericardium] 心包积血
· [Cerebral hemorrhage] 脑出血
· [Subarachnoid hemorrhage(SAH)] 蛛网膜下腔出血
· [Excessive (Heavy) menstrual flow with passage of clots] 月经量多伴血块
· [Mild (Moderate) menses] 月经量少(中等)
(8)紫绀的表示方法
· [Congenital cyanosis] 先天性紫绀
· [Enterogenous] 肠源性
· [Central] 中枢性
· [Peripheral] 周围性
· [Mixed] 混合性
· [Acrocyanosis] 指端紫绀
(9)恶心与呕吐的表示方法
· [Vomiturition (Retching)] 干呕
· [Feel nauseated] 恶心感
· [Postprandial nausea] 饭后恶心
· [Hiccup] 呃逆
· [Sour regurgitation] 返酸
· [undigested food Vomiting] 吐不消化食物
· [Bilious Vomiting] 吐胆汁
(10)腹泻与便秘的表示方法
· [Moning diarrhea] 晨泻
· [Watery (Liquid)diarrhea] 水泻
· [Mucous diarrhea] 粘液泻
· [Fatty diarrhea] 脂肪泻
· [Chronic (Acute)] 慢性(急性)
· [Mild diarrhea] 轻度腹泻
· [Intractable (Uncontrolled)diarrhea] 难治性腹泻
· [Protracted diarrhea] 迁延性腹泻
· [Bloody stool] 血梗
· [Frothy stool] 泡沫样便
· [Formless (Formed)stool] 不成形(成形)便
· [Loose (Hard) stool] 稀(硬)便
· [Rice-water stool] 米泔样便
· [Undigested stool] 不消化便
· [Dysenteric diarrhea] 痢疾样腹泻
· [Inflammatory diarrhea] 炎症性腹泻
· [Osmotic] 渗透性
· [Secretory] 分泌性
· [Malabsorption] 吸收不良性
· [Lienteric] 消化不良性
· [Pancreatic diarrhea] 胰性腹泻
· [Tenesmus
展开阅读全文