1、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
2、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 fac
3、e，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
4、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
5、 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 er
6、uption 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
7、 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(ri
8、b 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 or
9、thopnea 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
10、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 (diminut
11、ion, 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 (
12、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
13、 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
14、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
15、 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) pe
16、rcussion 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
17、第 2心音 (=， (=， )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(
18、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 级喷射型收缩期杂音 grade (I- /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
19、 (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
20、） 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
21、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
22、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 t
23、he 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 murphys 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 McBurneys point tenderness 腹肌强直（
24、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 tendern
25、ess 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 (b
26、leeding) 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 (Hemaf
27、ecia) 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
28、(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
29、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)
30、 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
31、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 pa
32、in) 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
33、 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) ed
34、ema 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
