【原創】病歷例句

谢谢！还有吗？

非常感谢楼主的无私奉献和辛勤工作，向楼主学习！！

谢谢楼主！
非常有用

虽说是从书上弄的，但省了我们太多时间。ddddd

谢谢，很好。强烈建议加分

第六節皮膚 (2)

毛髮
面部生許多毛 develop faical hirsutism
掉髮 lose one's hair; one's hair falls off (自然); (故意)拔掉毛髮 depilate
不長腋毛 do not grow axillary hair
眉毛和頭髮稀少且細 the eyebrows and scalp are sparse and fine
頭皮無毛 the scalp was bare of hair; loss of scalp hair
金髮或黑髮的(女孩) blonde or brunette (girl)
Ex1:毛髮的性狀和分佈情形正常
The quality and distribution of the hair are normal.
Ex2:雖然毛囊存在，但無腋毛與陰毛
There was absence of axillary and pubic hair although hair follicles were present.

3.腫瘤約有大蘋果那麼大，表面皮膚正常。
The tumor is roughly the size of a large apple and is covered with normally constituted skin.
腫瘤、腫物的大小
針頭大 pinhead size
罌粟大 size of a poppy seed
粟粒大 miliary size
米粒大 size of a rice grain
豌豆大 size of a pea
蠶豆大 size of a bean
胡桃大 size of a walnut
鴿卵大 size of a pigeon's egg
雞蛋大 size of a hen's egg
小(姆)指頭大 size of a small finger(thumb)
拳頭(手掌)大 size of a fist(palm)
小兒頭(大人頭)大 size of an infant's (a man's) head
形狀大，小，增大，減少 large small, increased, reduced (diminished) in size
腫脹忽變大忽變小 swelling waxed and waned
一壓即消失 disappear on pressure
腫瘤無顯著的增大 no obvious increase in the tumor's size
Ex1:起初腫塊是一個很小的結節，後來逐漸增大。
The mass started as a very small nodule and gradually increased in size.
Ex2:在左陰囊有大人拳頭大的腫瘤，由此連至鼠蹊管。
In the left half of the scrotum there is a tumor, as large as a man's fist, which is traced up to the inguinal canal.

一、主要調查項目：(revise on 3/8/06)

2.現症歷present illness：
→針對主訴的描述
-onset(date, mode):何時發生的？是急/慢性的？突然的？ insidious？
-duration before present entry :發病日期到這次住院的天數？之前有無做過什麼治療？
-prodromal symptoms:發病前有什麼其它症狀？
-course or progress( location, duration, severity, continuity, intermission, radiation,
treatment), aggravating and alleviating factors,:關於主訴的相關描述？
→LQQOPERA
L:location 位置
Q:quality 性質 ex: dull/colic pain
Q:quantity 疾病的程度 ex:對生活的影響/一天發生幾次？一次大概持續多久的時間(duration)？
O:onset 發生的 timing and mode ？
P:prodromal or precipitation factors 前驅/誘導因子; 在狀況發生之前，病人在做什麼事情？ ex:吃完大餐之後開始胸痛
E:exaggerating factors 加重因子 ex:身體前傾時腹痛加劇
R:relieving factors / radiaction 緩解的症狀的方式？/疼痛是否有遠端轉移的現象？
A: accompanying　symptoms 其它伴隨的症狀？ex:伴隨有噁心、吐嘔的現象
→General symptoms
-loss of weight, appetite and
strength, sleep, bowel movement, frequency of urination, menstruation, etc.
→Others
-exciting cause and environmental influences ex: 最近家裡有沒有人感冒; travel history, animal contact history ?
-其它針對主訴相關的問題

感謝大家的支持~~~

時間過的真快，小弟實習也快結束了，
不過，病歷還是寫的不是很好，所以小弟修改了一下之前文章的部份內容，藉以溫故知新並提供大家作參考；病歷的書寫實際應用是著重在臨床思路與鑑別診斷的工夫，所以小弟添加了自己的拙見，還請大家不吝指正與補充。

感激不盡！

楼主辛苦了
非常感谢，并大力支持您。
祝您生活，工作愉快。

不错！

第六節皮膚 (3)

4.在右上腹部有一個硬而平滑、無壓痛、可移動的腫塊，直徑約有4x5公分。
There was a firm, smooth, nontender, freely movable mass in the R.U.Q. measuring approximately 4 by 5 cm in diameter.

腫塊的硬度
軟的 soft
硬韌的 firm
硬的 hard
石頭似的 of stone-like
浮腫的 edematous
骨樣硬的 bony hard
軟骨樣的 cartilaginous
波動性的 fluctuating
緊張的 tense
有彈性的 elastic
泥土樣的 clay-like
壓縮性的 compressible

腫塊的形狀
扁平的 flat
平坦的 evenly flat
限局性 circumscribed
瀰漫性的 diffuse
不規則的 irregular
鬆弛的 flabby
凹凸不平的 uneven
溝狀的 furrowed
圓形 roundish; circular
半球狀的 hemispherical
球狀 globular
角狀 horn-shaped
卵圓形 oval
橢圓形 elliptical
紡綞狀的 spindle-shaped
菱形 rhombic
結節狀的 knotty; tuberous
有莖狀 pedunculated
水螅狀 polypus-shaped
蜂窩狀的 honeycomb
花椰菜狀 cauliflower-like

ex1:由體檢結果知，在左上腹部有一個8x3公分大的橢圓形腫物。
P.E. of the abdomen demonstrated an elliptical swelling of 8x3 cm in size (presenting) in the L.U.Q.
ex2:腫脹摸起來有牽張及彈性感，按捺時有壓痛。到處呈現波動狀。
The swelling was felt distended, elastic and tender on pressure. Fluctuation was also palpable all over the swelling.

淋巴結
ex1:頸部發腫得很厲害，但沒有甲狀腺或淋巴結腫大的跡象。
Neck fullness was quite pronounced without palpable evidence of thyroid or lymph node enlarement.

第七節　HEENMT & Neck (1)
1.他的頭形正常。
The shape (contour; outline) of his head is normal.

2.哭聲很大，無紫紺出現。
The cry was lusty, and there was no cyanosis present.

紫紺、氣色
有點(顯著的，中度的，輕度的，斑點的，全身性的) 紫紺 have slight (marked, moderate, faint, mottled, generalized) cyanosis
口唇和指甲發生一些(深度) 紫紺 have some (deep) cyanosis of the lips and nail beds
發生一時性紫紺 develop a transient period of cyanosis
口圍紫紺消失了 cricumoral (perioral) cyanosis diappeared
臉色好 the cheeks are ruddy (flushed; rosy; healty; florid)

哭聲
哭聲微弱 (大聲哭，用力哭，哭聲弱，低聲鼻鳴，無聲的哭) have a weak (loud, strong, faint, low whining, aphonic) cry
ex1:他的臉顏色蒼白，有點浮腫。
He has a pale, somewhat bloated face.
ex2:臉色發青，滿面冷汗。
The face is cyanotic and covered with cold sweats.

3.以年齡而言，他的左眼視力和屈折度完全正常。
The left eye was entirely normal, with normal vision and refraction for his age.

眼科檢查
常閃目 frequent blinking
斜視的 cross- (squint-) eyed
眼球外 (內，上，下) 斜轉 eye turns out (in, up, down)
眼瞼 (眼睛周圍，眼球) 紅腫 redness and swelling of the eyelids (area around the eye , eyeball)
把眼睛向外 (內)翻 evert (introvert) the eyelids
無明顯的神經缺陷 no obvious neruological defects
ex1:右眼在任何方面都正常。
The right eye is normal in all respects.
ex2:兩側散瞳，左側對無對光反射。
Both pupils were dilated and the left was fixed (to light).

二、病歷與時態 (補充)
Ex:
For several years he has been subject to bouts of transient giddiness and blurred vision on assuming an erect position from a prone or sitting position. These became markedly apparent during the past two months and he began to feel that he could not stand perfectly still for more than a few minutes without feeling in some way uncomfortable, but he could prevent this by walking about. He feels a dull aching in his hands and wrists which he can circumvent over his chest. There is no puffiness of his hands.

has been:
-現在完成進行式:可表示截至現在為止的動作或狀態的繼續
-表示一直到現在仍受昡暈的纏擾
became & began:
-過去式:可表示過去某時的事實、動作或狀態
-說明了這些症狀在最近兩個月中明顯了起來，同時開始有新的症狀
feels & is
-現在式:可表示現在的事實、動作或狀態
-表示現在手、腕有鈍覺性酸痛

多谢楼主啊
希望继续努力

非常感谢！

谢谢啊
真的是学无止境啊
向楼主学习啊

真的很感激
谢谢

强烈支持！写得太好了！很实用！

向楼主敬礼！收藏了。

很好，很实用！LZ是超级大好人！