病史书写的名词汇总

1、病史书写的名词汇总A. 一般项目 General Items姓名Name:性别Sex:Age:职业Occupation:民族Race:婚姻状况Marital status:住址Address:病史陈诉者Complainer:可靠性Reliability:入院日期Date of admission:记录日期Date of record:B. 主诉Chief complaint症状描述：a. 好转、减轻: alleviate, palliate, reduceb. 消失、消退: disappear,c. 加重、恶化: become worse (aggravated)d. 无变化: remain

2、the samee. 时好时坏: wane and wax, hang in the balance B. 主诉Chief complaint时间描述：cough with yellow sputum for five days black tarry stool of three days durationlow fever 2 weeks in durationtwo-day history of chest pain全身症状 (General)发热fever疼痛pain不适malaise疲倦lassitude；fatigue虚弱weakness；debilitating瘦wasting；

3、 thin；emaciation出汗sweating；perspiration多汗hidrosis发冷feel chilly畏寒chilly sensations寒战shivering；shaking chill瘙痒pruritus痒itchingA） 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chest pain心前区痛precordial pain；胸骨后痛retrosternal pain；胸部压榨感（压迫感；窒息感；紧缩感） squeezing ( pressing；chok

4、ing； tightness) sensation of the chest泡沫样痰frothy sputum活动后气促breathlessness of exertion阵发性夜间呼吸困难 paroxysmal nocturnal dyspneaC）消化系统胃灼热pyrosis腹痛abdominal pain胃痛stomachache厌食anorexia纳差poor appetite恶心nausea呕吐vomiting呕血hematemesis呕粪stercoraceous vomiting呕胆汁bilious vomiting嗳气belching返酸sour regurgitation饭后

5、腹胀postprandial distension便秘constipation腹泻diarrhea里急后重tenesmusD） 泌尿系统：无尿anuria尿浑浊cloudy urine绞痛colic浮肿edema腰痛lumbodynia；lumbago夜尿nocturia少尿 oliguria多尿polyuria排尿中断interruption E） 造血系统：出血bleeding皮肤出血点bleeding spots in the skin鼻出血epistaxis牙龈出血gum bleeding术后伤口出血postoperative wound hemorrhage血尿hematuriaF）

6、内分泌系统：贪食hyperorexia矮小dwarfism过高excessive height多汗excessive sweating手抖hands tremble肥胖obesity消瘦wasting烦渴polydipsia；excessive thirstG）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；menopauseH）神经系统：焦虑

7、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wandering paini)运动系统：关节痛arthrodynia；arthralgia背痛back pain腰痛lumbago；lurnbodynia足痛foot pain肢痛pain in limbs；acrodyniaj)皮肤科症状抓痒后渗血blood oozed o

8、ut after scratch an itch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dryness of the nose嗅觉丧失anosmia嗅觉减退hyposmia额部头痛frontal headache鼻塞nasal obstruction脓鼻涕purulent rhinorrhea鼻出血rhinorrhagia流鼻涕rhinorrhea打喷涕sneezing打鼾snoring水样鼻涕watery rhinorrhea咽部疾病咽下困难dysp

9、hagia声嘶hoarseness咽食时疼痛pain on swallowing咽喉痛sore throat声音沙哑throaty voice喘鸣stridorL)眼科视物模糊blurred vision；hazy vision复视diplopia闪光flashing lights异物感foreign body sensation失明lose the sight眨眼nictitation眼痛eye-ache；ocular pain眼花vertigoC. 现病Present illness起病方式：a. 急剧（暴发性）：fulminant, explosiveb. 突然：abrupt, sudd

10、enc. 迅速： rapidd. 缓慢：graduale. 偶然：accidentally, occasionallyC. 现病Present illness发作规律：a. 经常反复的：recurrent bouts, 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：aching pain； 坠痛：bearing-down pain；钻痛：boring pain；烧灼痛：burning pain；撕裂痛：bursting pain； 绞痛：colic； colic

11、ky ( or cramp; griping ) pain；痉挛性痛：cramping pain；钝痛：dull pain；束带样痛：girdle pain；跳痛：jumping pain；刀割样痛：knife-like pain；刀刺样痛：piercing pain；搏动性痛：throbbing pain疼痛的状态：持续性痛：persistent pain； unremitting pain ；经常性痛： constant pain；间歇性痛： intermittent pain；阵痛：labor pains；时痛时不痛：The pain came and went；疼痛的描述Pain疼痛的

12、变化：痛的发生与 有关：is associated with痛的减轻：grew less; is relieved by; the severity waned; 疼痛加剧：worsened；severe疼痛不停止：did not cease疼痛持续不变：pain was steady疼痛的位置：疼痛位于部位：limited to靠近什么部位：near局限于什么部位：localized or confined to转移到：pain shifts to; migrates to;痛向什么部位放射：radiates or refers to疼痛持续时间：last; continue发热Fever发

13、热的程度：高热：hyperpyrexia; high fever; ardent fever低热：slight fever; low-grade fever; subfebrile temperature 中度发热：moderate fever;体温变化：升高至：rise to; go up to; be elevated to急速降低：fall; decline; abates; drop; reduce（promptly; abruptly)缓慢下降：slow lysis (crisis) of fever不超过：do not exceed (go up over)在范围波动：fluctu

14、ate （vary; range）between 咳嗽Cough咳嗽的种类：干咳：dry (nonproductive) cough阵发性干咳：hacking cough 短咳：short cough剧咳：sharp cough带哮鸣音的咳嗽wheezing cough难咳：distressed cough浅咳：shallow cough刺激性咳嗽：irritable cough痉挛性咳嗽：spasmodic cough接连咳嗽：continually coughing阵发性咳嗽：paroxysmal cough痰咳：loose cough湿咳：wet (moist) cough痰Sputum

15、痰的性状：绿痰：aeruginosum sputum； aeruginous sputum血痰：bloody sputum 恶臭痰：fetid (foul) sputum粘液脓性痰mucopurulent sputum铁锈色痰：rusty sputum浆液痰：serous sputum透明痰：transparent sputum粘痰：viscous sputum大便Stool大便的性状：无胆色粪：acholic stool胆汁粪：bilious stool 干便：dry stool稀便：loose stool不成形便：formless stool黑粪：melena豆浆样便：pea-soup s

16、tool米泔样便：rice-water stool柏油样便：tarry stool不消化粪：undigested stool稀水便：watery (liquid) stool大便Stool大便的气味：恶臭：stench臭的：foul, fetid 非常臭：extremely foul不太臭：less offensive in odor无臭的：odorless味道难闻但不太臭的：offensive but not excessively foul 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：brownish blac

17、k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：bright red红色：red深棕色：dark-brown暗蓝色：dirty blue乳白色：milky橙黄色:orange棕黄色:brown yellow体格检查一般资料 General Condition体温：a. 口温: per mouth;

18、oral temperature;b. 腋温:per axilla; axillary temperature c. 肛温: per rectum; rectal temperaturea热型：a. 稽留热: continuous or sustained b. 周期性:periodic c. 弛张型: remittent or malarial 一般资料 General Condition脉搏种类：速脉: fast or rapid徐脉：slow 重脉： dicrotic pulse不规则脉：irregular pulse奇脉：paradoxical pulse水冲脉：water-hamme

19、r pulse间歇脉：intermittent or dropped-beat一般资料 General Condition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：buccal breathing不能察觉：imperceptible一般资料 General Condition呼吸类型：腹式呼吸: abdominal respiration深吸气性呼吸：apneustic respiration 周期性呼吸：periodic respiration鼾声呼吸：stertorous respira

20、tion叹息样呼吸：sighing respiration一般资料 General Condition呼气的气味：口臭: foul breath恶臭气息：fetid breath呼气口臭：offensive breath 甜而酸败的气味：a sweetish musty odor of the breath强烈酮味：a strong smell of ketone呼气丙酮味：an acetone odor on breath The examination revealed no dyspnea at rest with respiratory rate of 20/min.2. The pa

21、tient became extremely dyspnea.3. There is fetor hepaticus, ie a sweet, musty odor of the breath. 一般资料 General Condition体位：被动体位: passive position强迫体位：forced position平卧位：reclining position (horizontal，recumbent）仰卧位：supine position 侧卧位：lateral （decubitus）position特殊体位：蜷腿位:coiled position膀胱截石位：dorsosacr

22、al position胸膝位：knee-chest position膝肘位：knee-elbow position角弓反张位：opisthotonos position端坐呼吸位：orthopnea position偏侧卧位：unilateral position 一般资料 General Condition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 Gener

23、al Condition He was conscious and cooperative, and could answer all questions.2. The patient had a dull, expressionless lethargic face 3. He was in semicomatos state, reacting only to painful stimuli. 面容不安面容：anxious expression痛苦表情：distressing expression颜面潮红：flushing of the face；reddy face二尖瓣面容：mitra

24、l face；满月脸：moon face不适表情：pinched expression一般资料 General Condition发育身高：height of the body身材：stature体格：build，physique巨人：giant运动员体型：athletic type矮胖体型：stocky type一般资料 General Condition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；marasmu

25、s恶病质：cachexia一般资料 General Condition The patient exhibits mitral faces 2. He looks (or appears) acutely ill；He was in acute distress 3. He is a stocky build.4. Physical examination showed a striking wasting of the arms and legs as compared to the rest of the body.皮肤、粘膜颜色色素减退：depigmentation雀斑：fleck 潮红

26、：flush 面色红润：florid facies色素沉着过多：hyperpigmentation黄疸：jaundice；icterus (icteric)苍白：pallor; paleness紫纹：purple striae一般资料 General Condition皮肤、粘膜外观紫绀：cyanosis干燥：dry湿润：moist四肢湿冷：cold moist extremities温暖的：warm光滑的：glossy粗糙的：harsh；rough鳞状的：scaly一般资料 General Condition皮损斑疹：macule斑块：plaque 斑丘疹macule-papule丘疹：pa

27、pule玫瑰疹： rose spots疱疹：blebs脓疱：pus blister; pustule血疱：blood blister寻麻疹：hives urticaria一般资料 General Condition皮损囊肿：cyst 疤痕：scar皮屑：furfur结痂：crust溃疡：ulcer皲裂：fissure肝掌：liver palms蜘蛛痣：vascular spiders一般资料 General Condition Pallor appears upon elevation of the right foot 2. The lips, mucous membranes, and n

28、ail beds are markedly (moderately; faintly )cyanotic 3. Some spider nevi are seen over the upper thorax and shulders出血征瘀点：petechia紫斑：purpura瘀斑：ecchymosis血肿：hematoma片状出血：splinter hemorrhage渗血：oozing of the blood一般资料 General Condition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：o

29、ligotrichosis；一般资料 General Condition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 General ConditionThere are much small, red spots with 1 to 2 mm in diameter and dont blanch on pressure on his body2. The hair are fine, dry and brittle 3. There are 2

30、 movable, non-tender, not particularly firm lymph nodes in the right axillary region外形头围：head circumference头颅骨缝：cranial suture囟门膨出（凹陷）：bulging (depressed) fontanel长头：dolichocephalism短头：brachycephalism尖头：acrocephalia小头：microcephalismB. 头部（Cranium）眼右眼：oculus dexter （OD）左眼：oculus sinister （OS）眼球凹陷：sunk

31、en eyes；enophthalmos眼球突出：ocular proptosis；protruding eyes；exophthalmos眼球震颤：nystagmusB. 眼 （Eye）眼睑（eyelid）上睑下垂：ptosis眼睑痉挛：blepharospasm睑痉挛：blepharoptosis睑颤动：flickering lid兔眼：lagophthalmos常闪目：frequent blinking流泪：lacrimationB. 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

32、物：watery (purulent) dischargeB. 眼 （Eye）角膜（cornea）苍白：pallor透明的：transparent 浑浊的：opaque穿孔：perforation 异物：foreign body溃疡：ulcer老年环：arcus senilis角膜浸润：cornea infiltrationB. 眼 （Eye）瞳孔（pupil）瞳孔缩小：contraction of pupils瞳孔缩小：dilation of pupils瞳孔大小不一：uneveness of pupils 瞳孔对光反射：light reflex of pupils B. 眼 （Eye）1.

33、 The head is normocephalic； The shape of his head is normal； His head is normal in configuration； He has a normal-shaped head2. The hair are fine, dry and brittle 3. There are 2 movable, non-tender, not particularly firm lymph nodes in the right axillary region Sclerae are clear and anicteric 2. Cor

34、neal reflexes are good3. The pupils are unequal and react poorly to light4. The pupils shrink to as little as Imm in diameter,but retain their light reflexesB. 眼 Eye 视野 VisualField：完整的:Full；lntact偏盲:hemianopia单侧缺损:unilateral defects 双颞侧缺损:bitemporal detectsThe visual fields are full. There is hemian

35、opia of the left side.B. 眼 Eye 眼底 Fundus：动脉狭窄：arteriolar narrowing动静脉压迹：A V nicking微小动脉瘤：microaneurysm火焰样出血：flame hemorrhage点状出血：punctate hemorrhage视神经乳头水肿：papilledemaThe retinal veins become engorged.There are retinal hemorrhages and papilledema.B. 眼 Eye 视力 Vision：视力模糊：blurred vision；eye-blurred视力减

36、退：impaired vision；poor vision失明：amaurosis弱视：amblyopia手动：hand movernent光感：light perception数指：counting finger视觉敏锐：oxyopia复视：double vision斜视：cross-eye；squint，strabismusB. 眼 Eye 视力 Vision：近视：myopia；myopy远视：hyperopia；hypermetropiaThe vision of the left eye is 0. 2Short-sighted (Far-sighted): 200 degree,O

37、D; 175 degree, OSB. 眼 Eye 色觉 color perception：视力模糊：blurred vision；eye-blurred色盲：chromatodysopia全色盲：achromatopsia 绿色盲：achloropsia；green blindness蓝色盲：acyanoblepsia色弱：color weakness红绿盲：red-green blindness；anerythrochloropsiaB. 眼 Eye 色觉 color perception：He has red and green color blindnessHe has a color

38、 weaknessThe intraocular pressure ,30 mm Hg,OD；20mmHg, OSC. 耳 Ear鼓膜 drum；tympanic membrane：视力模糊：blurred vision；eye-blurred膨出：Bulge发红的：flushed内陷：Indrawing穿孔：perforation中央性穿孔：central perforation边缘性穿孔：marginal perforationC. 耳 Ear听力 hearing：听觉迟顿：amblyacousia；baryacusia听觉减退：hearing loss传导性耳聋：conductive d

39、eafnessHe could hear conversational Voice only within a distance of a meter on the right side.Hearing tests confirm the presence of conductive deafnessD. 鼻 Nose1. The examination reveals a saddle deformity of the nose2. There is a shallow ulcer (l. 5 by 1 cm) with a raised border on the nasal apex3.

40、 The mucosa and turbinates are within normal limits.D. 鼻 Nose4. The nasal mucasa is red and swollen, and the cavity contains watery secretion5. Rhinoscopy shows a pinkish soft friable mass, which bleeds easily on touch, arising from the middle meatus of the left nose6. Posterior rhinoscopy shows a s

41、mooth, greyish-white, spherical mass in the choanaD. 鼻 Nose嗅觉 Smell；Scent：嗅觉缺失；anosmia嗅觉迟顿；baryodmia嗅觉敏锐：oxyosphresiaAnterior rhinoscopy reveals the septum is markedly (acutely) deviated to the left.Posterior rhinoscopy shows mucopus on the superior surface of the soft palate.There is tenderness ove

42、r the frontal sinuses E. 口腔与咽 Mouth and pharynx粘膜与口唇 Smell；Scent：唇干裂：Cheilosis口臭：halitosis口唇疱疹：herpes labialsSome white plaques are on the oral mucosa, the plaque is scraped off with difficulty, exposing a red base.E. 口腔与咽 Mouth and pharynx牙齿 tooth：牙齿磨损；attrition of the tooth龋齿：dental caries (decaye

43、d teeth假牙：false teeth镶牙：insert teeth牙齿松动：loosening of the tooth牙齿脱落：lose a tooth牙髓炎：pulpitis牙石：tartar (dental calculus)牙关紧闭：trismus; clenching of the teethHis 2nd molar is decayed toothE. 口腔与咽 Mouth and pharynx舌 tongue：舌苔：coated tongue, furred tongue地图舌：geographic tongue舌面光滑：smooth tongue草莓舌：strawbe

44、rry tongue1. The tongue is moist and well papillated with no coating2. Creamy-white plaques are found on the tongueE. 口腔与咽 Mouth and pharynx咽和扁桃体 pharynx and tonsil：1. There is no enlarged tonsils, and no injection and exudate on the pharynx2. The lymphoid follicles on the posterior pharyngeal wall

45、are obvious as discrete nodules3. The tonsils are congested, swollen and studded with yellow beads of pus.E. 口腔与咽 Mouth and pharynx喉 larynx：失声：aphonia; loss of voice尸位：cadaveric position哑dumbness；mutism声嘶：hoarseness变音：mutation of voice喉 larynx：1. His voice is peculiar and likes a duet2. At laryngosc

46、opy there are bunches of wart-like excrescences of the larynx, pinkish-white in color3. Vocal cords are edematous and pus is seen in the interarytenoid region and around the epiglottis 4. Indirect laryngoscopy shows the left vocal cord in paramedian positionE. 口腔与咽 Mouth and pharynx角弓反张：opisthotonos

47、软的；supple颈强直：stiff-neck；nuchal rigidity（静脉）怒张：distention and prominence平坦：flat充盈：full, engorged肝颈静脉反流：hepatojugular reflex震颤：thrill甲状腺肿大：goiter, enlarged thyroid气管偏移：tracheal deviationF. 颈部 Neck1. The breasts are normal female without masses or discharge2. There are slight nipple retraction and bloo

48、dy discharge from the nipple of the right breaat3. A nontender, firm lump with 2 by 3 cm in diameter in palpated in the upper outer quadrant of the left breast四、胸部 Chest4. The chest demonstrated a lipoma on the right anterior chest wall5. The patient had a laceration present at the left 8th intercos

49、tal space.6. There is no abnormality of the ribs.四、胸部 Chest肺 lung （Inspection）：胸腔前后径：anteroposterior diameter of the chest端坐呼吸：orthopnea三凹征：depression of three fossae (retraction sign)桶状胸：barrel chest鸡胸：chichen (or pigeon) chest漏斗胸：funnel chest佝偻病胸：rachitic chest四、胸部 Chest肺 lung （Palpation）：触觉性震颤：ta

50、ctile fremitus胸膜摩擦：pleural frictional feeling语音震颤：vocal fremitus1. The fremitus is equal bilaterally2. The tactile fremitus is diminished at the right base肺 lung （Percussion）：浊音：dullness实音：flatness过度反响：hyperresonance清音：vesicular鼓音：tympany；tympaniticresonance1. Both lungs are resonant to percussion2.

51、 The chest shows increased resonance to percussion over the left side3. Dullness to percussion appears in left lung肺 lung （Auscultation）：支气管音：bronchophony支气管肺泡音：bronchovesicular sounds空洞语音：caverniloquy粗大罗音：coarse (medium, fine) rale捻发音：crepitant rales支气管语音：egophony吸气末细湿罗音：fine end-inspiratory rales

52、湿罗音：moist（bubbling）rales胸膜摩擦音：pleural friction rub咳嗽后：post-tussive鼾音：rhonchi； sonorous rales粗糙呼吸音：rough breath sound肺 lung （Auscultation）：哮鸣音：wheezes; wheezing飞箭音：sibilant rales管状（支气管）呼吸音：tubular (bronchial) breath sounds肺泡呼吸音：vesicular breath sounds整个肺野：entire (or whole) lung field右上肺：the right upp

53、er lung中前胸部：the middle of the chest anteriorly左肺上1/3处：the upper one-third of the left chest肺 lung （Auscultation）：1. Diminished (exaggerated) breath sounds on auscultation appear in the right upper lung2. There are tubular breath sounds over the left lower lung3. There are large moist rales in the ri

54、ght between the 4th and 8th ribs anreriorly4. Scattered high pitched rhonchi over both lung fields心脏 heart （Inspection）：隆起：bulge；heave弥散的：diffuse肋间隙：ICS= intercostal space锁骨中线：MCL=mid calvicular line最强搏动点：PMI= point of maximum impulse心尖搏动：apical impulse；apex beat 震颤：(systolic) diatolic thrill四、胸部 Ch

55、est心脏 heart （Palpation）：1. The apex beat can be felt in the 5th interspace 1 cm inside the left mammilary line2. Apex beat is forceful and enlarged3. Apical impulse is difficult to feel4. Apical impulse displaced significantly to the left and down5. Systolic thrill is palpated at the second intercostal space of left sternal border心脏 heart （Percussion）：心脏绝对（相对）浊音界：Absolute (relative) cardiac (dullness)1. The heart size is