临床病症病历英文单词

1、immunizationsallergen:预防接种史过敏史无有临床表现过敏原traumahistory:surgeryhistory:CaseRecords表格式住院病历Biographicaldata:一般工程NameAgeSexMaritalstatusNativeplaceRace姓名年龄性别婚否籍贯民族OccupationDateofadmissionInformant职业入院日期病史表达者History病史Chiefcomplaint:主诉Historyofpresent川ness:现病史Pasthistory:既往史previoushealthstatus:wellordinar

2、ybadinfectiousdiseases平素健康状况良好一般较差传染病史allergies:NYclinicalmanifestation:外伤史手术史Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpositive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)系统回忆有打,无打x阳性病史应在下面空间内填写发病时间及扼要诊疗经过Respiratorysystem:呼吸系统sorethroatchroniccoughsputumhemop

3、tysiswheezingdyspneachestpain胸痛咽痛慢性咳嗽咳痰咯血哮喘呼吸困难Cardiovascularsystem:循环系统palpitationdyspneaonexertionhemoptysissyncopeedemaoflowerlimbsprecordialpainhypertention心前区痛心悸活动后气促咯血晕厥下肢水肿高血压Digestivesystem:消化系统anorexiasourregurgitationbelchingnauseavomitabdominaldistentionabdominalpain腹痛食欲减退反酸暧气恶心呕吐腹胀consti

4、pationdiarrheahematemesismelenahematocheziajaundice便秘腹泻呕血黑便便血黄疸Urinarysystem:泌尿系统lumbagofrequentmicturitionurgentmicturitionurodyniadysuriahematurianocturia夜尿腰痛尿频尿急尿痛排尿困难血尿polyuriaoliguriafacialedema多尿少尿面部水肿Hemopoieticsystem:造血系统fatiguedizzinessblurredvisiongingivalbleedingsubcutaneoushemorrhageoste

5、algiaepistaxis乏力头昏眼花牙龈出血皮下出血骨痛鼻妣Metabolicandendocrinesystem:代谢及内分泌系统excessiveappetiteanorexiasweetscoldintolerancepolydipsiapolyuriatremorhandschangeofcharacter食欲亢进食欲减退多汗畏寒多饮多尿双手震颤性格改变obviousobesityemaciationhairinesshairlosingpigmentationchangeofsexualfunctionamenorrhea显著肥胖消瘦多毛毛发脱落色素沉着性功能改变闭经Muscul

6、oskeletonsystem:肌肉骨骼系统floatingarthralgiaarthralgiaswellingofjointsdeformitiesofjointsmyalgiaatrophyofmuscle游走性关节痛关节痛关节红肿关节变形肌肉痛肌肉萎缩Nervoussystem神经系统dizzinessheadachevertigosyncopedegenerationofmemoryvisualdisturbanceinsomnia头昏头痛眩晕晕厥记忆力减退眠视力障碍失disturbanceofconsciousnesstremorspasmparalysisparesthesia

7、意识障碍颤抖抽搐瘫痪感觉异常Personalhistory:个人史birthplaceoccupationsexualhistory:NYsmoking:NYaboutyrsaveragepieces/d出生地职业冶游史无有吸烟无有约年平均支/日ceasedforyrsalcoholintakeaverageml/dothers:Noccasionalfrequentaboutyrs戒烟日其它嗜酒无偶有经常年平均ml/Maritalhistory:婚姻史marryingagecompanionsstateofhealth结婚年龄配偶健康状况MenstruationandChildbearing

8、history:月经及生育史lastingfordaysmenarcheagecycledaysdateoflastperiodageofmenopause初潮每次持2时间天周期天末次月经时间绝经年龄amountofflow:littlenormallargemenstrualpain:NYcycle:regularirregular经量少一般多痛经无有经期规那么不规那么pregnancy:timesnaturallabortimesabortionstimesprematuredeliverytimesstillbirthstimes妊娠次顺产胎流产胎早产死产胎difficultlabora

9、nditscondition:难产及病情Familyhistory:payattentiontothecongenitaldiseasesandcommunicablediseasesrelatedtothepatient家族史注意与患者现病有关的遗传病和传染性疾病father:stillalive川nessdiedcauseofdeathmother:stillaliveillnessdiedcauseofdeath已故父健在患病已故死因母健在患病死因siblings:others:兄弟姐妹子女及其他Physicalexamination体格检查Vitalsigns:temperatureC

10、pulse/minrespiration/minbloodpressure/mmHg生命体征体温C脉搏次/分呼吸/分血压/mmHgGeneralAppearance:一般状况development:ortho-sthenictypeasthenictypesthenictypenutrition:wellfairlypoorcachexia发育正常不良超常营养良好中等不良恶病质facialfeatures:normalacutechronicothersexpressions:naturalpainfulanxiousdreadfulindifferent面容无病容急性慢性病容其他表情自如痛苦

11、忧虑恐惧冷淡position:activesemi-recumbentothersgait:normalabnormal体位自主半卧位其他步态正常不正常consciousness:awaresomnolenceconfusionstuporcomadeliriumcooperation:wellbadly神志清楚嗜睡模糊昏睡昏迷澹妄配合检查合作不合作Skin,mucousmembrane:color:normalredpalecyanosisyellowpigmentationrash:NY(typeanddistribution)皮肤粘膜色泽正常潮红苍白紫绢黄染色素沉着皮疹无有(类型及分布)

12、subcutaneoushemorrhage:NY(typeanddistribution)hair:normalscatteringlosing(position)皮下出血无有(类型及分布)毛发分布正常稀疏脱落(部位)moistureandtemperature:normalcolddrywetelasticity:normalreducededema:NY(positionanddegree)正常冷干湿弹性正常减退水肿无有温度与湿度部位及程度hepaticpalm:NYspiderangioma:NYpositionnumbersothers:肝掌无有蜘蛛痣无有部位数目其他:Lymphno

13、des:淋巴结Superficiallymphnodes:non-swellingswelling(positionandcharacteristics)全身浅表淋巴结无肿大肿大(部位及特征)Head:头部cranium:size:normallargesmalldeformity:NY(oxycephalysquaredskulldeformingskull)头颅大小：正常大小畸型无有(尖颅方颅变形颅)others:tendernessmasssunk(position)其他异常压痛包块凹陷(部位)eyes:eyelid:normaledemaptosistrichiasisconjunct

14、ive:normalhyperemiaedemahemorrhage眼眼睑正常水肿下垂倒睫结膜正常充血水肿出血eyeball:normalexophthalmosdepressiontremormotiondysfunction(leftright)眼球正常突出右凹陷震颤运动障碍左sclera:normalyellowcornea:normalabnormal(leftright)pupils:equalroundness巩膜无黄染黄染角膜正常异常(左右)瞳孔等圆samesizeunequalleftcm,rightcmreactiontolight:normaldelay(leftright

15、)等大不等左cm,右cm对光反射正常迟钝左disappear(leftright)others:消失(左右)其他ears:auricle:normaldeformityfistulaothers(leftright)excretionsofexternalcanal:NY(leftrightfeature)耳耳廓正常畸型屡管其他(左右)外耳道分泌物无有(左右性质)tendernessofmastoid:NY(leftright)auditiondysfunction:NY(leftright)乳突压痛无有(左右)听力障碍无有(左右)nose:shape:normalabnormal()othe

16、rabnormalities:NYnasalaleflapobstructionexcretions鼻外形正常异常()其他异常无有鼻翼扇动鼻塞分泌物nasalsinustenderness:NY(position)鼻窦压痛无有(部位)mouth:lips:redcyanosispaleherpesfissuremucous:normalabnormal(palebleeding)口唇红润发绢苍白疱疹破裂粘膜：正常异常(苍白出血点)openingofparotidglandduct:normalabnormal(swellingpyogenicexcretions)腮腺导管开口正常异常(肿胀脓性

17、分泌物)tongue:normalabnormal(coveringstremorleaningtoleftorright)gums:normalswellingpusoverflow舌正常异常(舌苔伸舌震颤向左、右偏斜)牙龈正常肿胀溢脓hemorrhagepigmentsleadlineteeth:regularedentulouscariousteethfalsetooth出血色素沉着牙列齐缺牙幽牙义牙tonsils:pharynx:voice:normalhoarse扁桃体咽声音正常嘶哑Neck:resistance:NYcarotidarterypulsation:normalincr

18、easeddecreased(leftright)颈部反抗感无有颈动脉搏动正常增强减弱(左右)jugularvein:normaldistentionhighdistentiontrachea:middledeviationto(leftright)颈静脉正常充盈怒张气管正中偏移(向左向右)hepatojugularreflux:(-)(+)thyroid:normalswellingdegreesymmetrydominanceinoneside:肝颈静脉回流征(-)(+)甲状腺正常肿大度对称侧为主spreadingnodular:softhardothers:NY(tendernesstr

19、emorbruits)弥漫性结节性质软质硬其他异常无有(压痛震颤血管杂音)Chest:topography:normalbarrelchestflatchestpigeonchestfunnelchestbulgingorretraction(leftright)胸部胸廓正常桶状胸扁平胸鸡胸漏斗胸膨隆或凹陷(左右)bulgingintheprecordialregiontendernessofsternum心前区膨隆胸骨压痛breast:normalsymmetricalabnormal:leftright(gynecomastiamasstendernessexcretionsofnippl

20、es)乳房正常对称异常左右(男子乳房发育包块压痛乳头分泌物)Lung:肺inspection:movementofrespiration:normalabnormal:leftright(increaseddecreased)视诊呼吸运动正常异常：左右(增强减弱)intercostalspace:normalwidenarrow(position)肋间隙正常增宽变窄(部位)palpation:vocalfremitus:normalabnormal:leftright(increaseddecreased)pleuralfrictionrubs:NY(position)触诊语颤正常异常：左右(

21、增强减弱)胸膜摩擦感无有(部位)percussion:resonanceabnormal:dullnessflatnesshyperresonancetympany叩诊正常清音异常叩诊音浊音实音过清音鼓音lowerborders:scapularline:rightintercostalspaceleftintercostalspace肺下界肩胛线右肋间左肋间rangeofmobility:rightcm,leftcm移动度右cm,左cmauscultation:breath:regularirregular听诊呼吸规整不规整breathsound:normalabnormal(feature

22、,position)呼吸音正常异常(性质,部位描写)rales:NY:ronchi:sonoroussibilant罗音无有干性鼾音哨笛音moistrales:coarsemediumfineralescrepitus湿性大中小水泡音捻发音(部位见图)vocalconduction:normalabnormal:reducedincreased语音传导正常异常减弱增强pleuralfrictionrubs:NY(position)胸膜摩擦音无有(部位)Heart:心inspection:bulginginprecordialregion:NYapeximpulse:normalunseenin

23、creaseddiffusing增强弥视诊心前区隆起无有心尖搏动正常未见散position:normaldeviation(thedistancefrommidclavicularlinecm)心尖搏动位置正常移位(距左锁中线内外cm)otherprecordialpulsations:NY(position)其他部位搏动无有部位palpation:apeximpulse:normalincreasedthrustunclearthrills:NY(positionperiod)触诊心尖搏动正常增强抬举感触不清震颤无有(部位时期)pericardialfrictionrubs:NY心包摩擦感无

24、有percussion:relativecardiacoutline:normalshrinkextant(rightleft)叩诊相对浊音界正常缩小扩大(右左)right(cm)intercostalspaceleft(cm)右(cm)肋间左(cm)锁中线距前正中线距离(cm)auscultation:heartratebpm/minrhythm(regularirregularabsolutelyirregular)听诊心率次/分心律(齐不齐绝对不齐)heartsound:S1normalincreaseddecreasedsplitS2normalincreaseddecreasedsp

25、lit心音S1正常增强减弱分裂S2正常增强减弱分裂S3NYS4NYA2P2S3无有S4无有A2P2extraheartsound:Ngallop(diastolicpresystolicsummationgallop)openingsnapothers额外心音无奔马律(舒张期收缩期前重叠性)开瓣音其他murmurs:NY(degreeconduction)杂音无有图示并描述强度、传导apicalregionaorticareapulmonaryareatricuspidarea心尖部主A瓣区肺A瓣区三尖瓣区leftsternalborderin3ndintercostalspaceperica

26、rdialfrictionrubs:NY胸骨左缘第3肋间心包摩擦音无有Peripheralvessels:normalpistolshot:NYDuroziezsign:NYwaterhammerpulse:NY周围血管无异常血管征枪击音无有杜柔双重音无有水冲脉无有capillarypulsation:NYpulsedeficit:NYparadoxicalpulse:NYpulsusalternans:NYother毛细血管搏动无有脉搏短细无有奇脉无有交替脉无有其他Abdoman腹部inspection:shape：normaldistentionfrogbellycmscaphoidabd

27、omenapicalbelly视诊外形正常膨隆蛙腹腹围cm舟状腹尖腹gastricpatternintestinalpatternperistalsisabdominalrespiration:existdisappear胃型肠型蠕动波腹式呼吸存在消失umbilicus:normalprotrudingexcretions脐正常凸出分泌物others:NYvenousdistentionofabdomenpurplestriaesurgicalscarshernia其他异常无有腹壁静脉曲张条纹手术疤痕疝palpation:softmuscletensionpositiontenderness:

28、NYreboundtenderness:NY触诊柔软腹肌紧张部位压痛无有反跳痛无有fluidthrill:NYsuccusionsplash:NYmasses:NYpositionsize液波震颤无有振水音无有腹部包块无有(部位大小见图示)descriptionoffeature:特征描述liver:nottouchedbetouched:subcostalcm肝未触及可触及：肋下cmdescriptionoffeature:特征描述gallbladder:nottouchedbetouched:sizecm胆囊未触及可触及大小cmtenderness:NYMurphyssign:(+)(-)

29、压痛无有Murphy征阳性阴性spleen:nottouchedbetouched:fromcostalmargincm脾：未触及可触及肋下cmdescriptionoffeature:特征描述kidney:nottouchedbetouched:sizeconsistencytendernessmobility肾未触及可触及大小硬度压痛移动度tendernessofureters:NY(position)输尿管压痛点无有(部位)percussion:bordersofliverdullness(existshrinkobliteration)叩诊肝浊音界(存在缩小消失)upperborder

30、ofliver:onrightmidclavicularlineintercostalspace肝上界位于右锁骨中线肋间shiftingdullness:NYtendernessinrenalregion:NY(rightleft)移动性浊音无有肾区叩痛无有(左右)auscultation:gurglingsound:normalincreaseddecreaseddisappearvesselbruits:NY(position)听诊肠鸣音正常亢进减弱消失血管杂音无有(部位)Genitalia:notexaminednormalabnormal:生殖器未查正常异常RectumandAnus:

31、notexaminednormalabnormal:肛门直肠未查正常异常SpineandExtremities:脊柱四肢spine:normaldeformities(lateralanteriorposteriorprotruding)脊柱正常畸型(侧前后凸)acanthi:tendernesspainatpercussion(position)mobility:normalrestricted棘突压痛叩痛(部位)活动度正常受限limbs:normalabnormaldeformityswellingofjointsjointsstiffnesstendernessofmuscles四肢正常异常畸型关节