diagnosis七年制中英文教程.docx

diagnosis七年制中英文教程.docx

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diagnosis七年制中英文教程

Whatisdiagnosis?

什么叫诊断？

Diagnosisisinvestigationandjudgment.诊断就是诊察和判断Investigationisdatacollecting.诊察是收集疾病信息Judgmentissynthesisandanalyzedatatodeterminethenatureofillness.判断是综合分析信息确定所患疾病Thediagnosisistakingaboutthemethodofdatacollectingandhowtomakeacorrectjudgment.诊断学讲述收集信息和正确判断疾病的方法

StepsofDiagnosis诊断步骤DatacollectinghistoryintervewingphysicalexaminationlaboratoryexaminationassistantexaminationDataanalyzingDeterminationofthenatureoftheillness

收集信息资料采集病史体格检查实验室检查辅助检查推理分析判断确定所患疾病

ClassificationofClinicalDiagnosis临床诊断的分类EtiologicdiagnosisVirushepatitisRheumaticheartdisease

Pathological-anatomicdiagnosisAorticregurgitationLivercirrhosisPathophysiologicdiagnosisShockUremia

病因诊断病毒性肝炎风湿性心脏病

病理解剖诊断主动脉瓣关闭不全肝硬化

病理生理诊断休克尿毒症

Inquiry问诊Inquiryisonemethodfromtheinterviewbetweendoctorandpatientorrelativefordiseasehistory,andmakingtheclinicaldeterminationbyanalyzinghistory.

通过对患者或相关人员的询问获取病史资料经过综合分析作出临床判断

ContentsofQuestioning问诊的内容IdentifyinginformationSourceandreliabilityChiefcomplaintsPresentillnessPastmedicalhistoryPersonalhistoryMaritalhistoryMenstrualandobstetrichistoryinwomenFamilyhistory

患者个人信息叙述者和可信度主诉现病史既往史个人史婚姻史月经生育史家族史

IdentifyingInformation患者个人信息NameSexandAgeNativeplaceBirthplaceNationalityMarriageAddressWorkplaceOccupation

姓名性别和年龄籍贯出生地国籍或民族婚姻住址工作地点职业OthersInformation其他相关信息

ChiefComplaint主诉

Maindiscomfortanditsduration

Makesuretobe:

concisesequentialpersistingheadachefor3days

Makesuretoavoidusing:

onsettimeofthediseasediagnostictermsdialects

主要痛苦+经过时间

书写注意要简明扼要要按时间先后顺序持续头痛3天

三不要不要用起病时间不要用诊断术语不要用方言土语

PresentIllness现病史

Furtherdescriptionofthemaincomplaint,includingthewholediseaseprocessOnsetanddurationandPredisposingfactorsCharactersofthemainsymptom,progressionandevolvementAccompanysymptomsManagementsandeffectsEffectsondailylife

对主诉的进一步阐述起病情况和诱发因素主要症状特点和疾病的演变伴随症状诊疗经过对日常生活的影响

PastMedicalHistory既往史PasthealthstatusPastillnessHistoryofinjuryHistoryofsurgeryHistoryofallergyHistoryofbloodtransfusionHistoryofvaccinationSystemicreview

既往健康状况既往所患疾病既往外伤史手术史过敏史输血史预防接种史系统回顾

PersonalHistory个人史Homeplace,inhabitationplace,epidemicdiseaseortravelexperiencetoepidemicareaSmokingandalcoholintakeWorkHousingconditionLifestyleSexhistory

出生地居留地是否到过疫区烟酒嗜好职业特点居住条件生活习惯不洁性交史

MaritalHistory婚姻史Marriageage结婚年龄Healthstatusofthespouse爱人健康状况Maritalattachment夫妻感情

MenstrualandObstetricalHistory月经生育史Formulaforrecordingmensesintermenstrualperiod（day）Menarcheage————menopauseagemenstrualcycleorLMPMenses:

volume,color,leucorrhea,dysmenorrhealObstetrical:

numberofpregnancyanddelivery,historyofoperativedelivery,difficultlabor,abortion

月经记录格式行经期（天）初潮年龄————末次月经日期月经周期或绝经年龄行经情况月经量颜色有无白带痛经孕产情况孕次产次有无手术产流产难产

FamilyHistory家族史HealthstatusofthreesequentialgenerationsCausesofdeathExistingthesamediseaseHereditarydiseasesInfectiousdiseases

三代人健康状况父母兄妹子女（几男几女）死亡原因有无同类疾病遗传病传染病

BasicExaminationTechniques基本检查法视诊inspection触诊palpation叩诊percussion听诊auscultation嗅诊olfactoryPalpation触诊Lightpalpation浅部触诊法Deeppalpation深部触诊法Deepslippingpalpation滑行触诊法Bimanualpalpation双手触诊法Deeppresspalpation深压触诊法Ballottement冲击触诊法

PercussionNotes叩诊音Tympany:

gasHyperresonance:

increasedgasinlungtissueResonance:

lungtissueDullness:

gasandtissueFlatness:

essentialorganorfluid鼓音:

气体过清音:

肺组织含气增多清音:

肺组织浊音:

气体与组织实音:

实质脏器或液体

GeneralExamination一般检查Vitalsigns生命体征Development发育Habitus体型Nutritionalstatus营养Consciousness意识Facialfeaturesandexpressions面容和表情

VitalSign（T,P,R）生命征TemperatureNormalaxillaryT:

36~37℃Fever:

T>37℃Hypothermia:

T<35℃PulseFrequency:

60~100/minRhythm:

RegularRespirationNormal:

16~18/min体温正常（腋窝）体温:

36~37℃发热:

T>37℃体温不升脉搏脉率:

60~100/min节律:

整齐呼吸频率:

16~18/min

DisturbanceofConsciousness意识障碍Somnolence嗜睡Confusion意识模糊Stupor昏睡Coma昏迷Delirium谵妄

FacialFeaturesandExpression面容与表情mitralface二尖瓣面容Acutediseaseexpression急性病容Chronicdiseaseexpression慢性病容Specialface特殊面容GravesDisease甲亢面容MoonedFaceInducedbyCushing’s库兴氏满月脸HippocraticFacies恶病质

Myxedema粘液水肿Acromegaly肢端肥大症

Position体位Relaxedposition自主体位Positiveposition被动体位indepletionorunconsciouspatient极度衰竭意识丧失Compulsiveposition强迫体位torelievediscomfort减轻痛苦被迫采取的体位

Gait步态Normal:

calmandpithinessAbnormal:

WaddlinggaitDrunkenmangaitAtaxicgaitFestinatinggaitsteppageorfootdropgaitscissorsgaitIntermittentclaudicationspastichemiparesis正常:

平稳有力异常:

蹒跚步态醉酒步态共济失调步态慌张步态跨阈步态剪刀步态间歇性跛行划圈步态、

SubcutaneousHemorrhage皮下出血Winecolorandwon’tfadewhenpressed暗红色压之不褪色Petechia:

<2mm瘀点:

<2mmPurpura:

3~5mm紫癜:

3~5mmEcchymosis:

>5mm瘀斑:

>5mmHematoma:

血肿:

片状出血伴皮肤隆起

SpiderAngioma蜘蛛痣Highlybranchedstellatearteriallesionswhichpulsateandblanchonpressure.Distributedcommonlyonface,neck,orchest.Maybeassociatedwithpregnancy,chronicliverdisease,orestrogentherapy,ormaybenormal.

定义:

小动脉末端分支性扩张特点:

中央受压血管消失机制:

雌激素增多部位:

上腔静脉区域面部颈部和胸部病因:

妊娠慢性肝脏病变雌激素治疗

Recordcontent记录内容Normalnode:

2~5mm,soft,smooth,notendernessandadhesion.Recordifenlarged:

location,size,number,hardness,tender,mobility,adhesion,superficialskin.正常淋巴结2~5mm质软光滑无压痛无粘连肿大时记录部位大小数目硬度压痛活动度粘连PupilSize

瞳孔大小Normal:

3~4mmDilation:

glaucoma,atropinizationContraction:

organophosphoruspoisoning,drugreaction,narcotictakingPlatycoria:

dying正常:

3~4mm扩大:

青光眼阿托品中毒缩小:

有机磷中毒药物反应安眠药过量双侧散大:

濒死状态CompareBothPupil比较双侧瞳孔Normal:

SymmetryAnisocoria:

Pathologyanywherefromthereceptionoflightthroughtheopticnervestothebrainstem,thethirdcranialnerve,sympathetic,orparasympatheticpathwaysCerebralhernia正常:

等大等圆不等大视神经至脑干病变动眼神经受压交感神经受压副交感神经受压脑疝表面皮肤情况

Sinuses鼻窦Location部位frontalsinuses额窦ethmoidsinuses筛窦maxillarysinus上颌窦Sphenoidsinusestenderness&percussionpain:

sinusitis鼻窦区压痛叩击痛:

鼻窦炎

TongueSize舌体Enlarged:

inflammation,myxedema,tumor,acromegaly舌体肿大:

炎症

黏液性水肿肿瘤肢端肥大症Shrinked:

severedehydration舌体干小:

严重脱水AppearanceofTongue舌象Geographicandwrinkledorfissuredtongue:

riboflavindeficiencyStrawberrytongue:

longfeverBeefytongue:

niacindeficiencySmoothtongue:

ironorVitB12deficiencyBlackhairytongue:

fungusinfection地图舌和裂纹舌:

黄色斑片和横向裂纹提示核黄素缺乏草莓舌:

舌乳头肿胀长期发热牛肉舌:

舌面绛红菸酸缺乏镜面舌:

光滑红色铁或维生素B12缺乏黑毛舌:

黑黄褐色毛真菌感染

PharynxandTonsil咽和扁桃体Pharynx咽Turkeyredaccompaniedbyswelling:

Acutepharyngitis红肿:

急性咽炎Wineaccompaniedbyfollicle:

Chronicpharyngitis

暗红滤泡:

慢性咽炎Tonsil扁桃体degreeoftonsilswellingⅠ°不超过腭咽弓Ⅱ°超过腭咽弓未达中线Ⅲ°达到超过咽后壁中线purulent化脓性扁桃体炎

PalpationoftheTrachea触摸气管位置Indicatethelocationofmediastinum指示纵隔位置Location:

normallyinthemiddle正常居中Shiftingtothehealth:

largepleuraleffusion,pneumothorax移向健侧:

大量胸腔积液气胸Shiftingtothedisaster:

emphysema移向患侧:

肺不张

TheDegreeofThyroidGlandSwelling甲状腺肿大的分度Ⅰ:

invisiblebutpalpable不能看到能触到Ⅱ:

visibleandpalpable能看到又能触到Ⅲ:

exceedingtheoutmarginofsterno-mastoidmuscle超过胸锁乳突肌外缘

AbnormalIntercostalSpace肋间隙改变Recessedornarroweddepressedwheninspirating:

airwayobstructionone-sidedepression:

atelectasis,pleuraladhesionWideorswellinggeneralintensewhenexpirating:

emphysema,bronchialasthmaone-sideintense:

pleuraleffusion,pneumothorax

凹陷或变窄（容积缩小）吸气时凹陷:

大气道阻塞一侧变窄凹陷:

肺不张胸膜粘连膨隆或增宽（容积增大）呼气时膨隆:

肺气肿支气管哮喘一侧增宽膨隆:

胸腔积液气胸

AbnormalLungBorder肺界异常Kronig’isthmus:

Widening:

emphysemaNarrowing（unilateral）:

tuberculosis,tumorInferiorborder:

Lowered:

emphysemaRised:

atelectasis,increasedintra-abdominalpressureUndetectable:

Pleuraleffusion,pneumothorax

肺上界增宽:

肺气肿变窄:

肺结核肺肿瘤

肺下界下降:

肺气肿升高:

肺不张腹压增高叩不出:

胸腔积液气胸、

AbnormalDiaphragmaticExcursion肺下界移动范围异常Decreased:

<4cm减弱:

<4cmUnilateral:

atalectasis,pleuraladhension单侧:

肺不张胸膜粘连Bilateral:

emphysema,lungfibrosis双侧:

肺气肿肺纤维化

AbnormalIntercostalSpace肋间隙改变Recessedornarroweddepressedwheninspirating:

airwayobstructionone-sidedepression:

atelectasis,pleuraladhesionWideorswellinggeneralintensewhenexpirating:

emphysema,bronchialasthmaone-sideintense:

pleuraleffusion,pneumothorax凹陷或变窄（容积缩小）吸气时凹陷:

大气道阻塞一侧变窄凹陷:

肺不张胸膜粘连膨隆或增宽（容积增大）呼气时膨隆:

肺气肿支气管哮喘一侧增宽膨隆:

胸腔积液气胸

Chestshape胸廓形态Normal:

Ap:

T=1:

1.5Abnormal:

FlatchestandBarrelchestRachiticchestPigeonchestRachiticrosaryFunnelchestHarrisongrooveRegionaltransfigurationThorax-vertebrae-malformation-induced胸廓正常形态前后径:

横径1:

1.5胸廓形态异常扁平胸和桶状胸佝偻病胸鸡胸串珠胸漏斗胸肋膈沟局部变形胸椎严重畸形

PathologicalConditions异常改变Weakenordisappear:

Obstructiveatelectasis,emphysema,Pleuraleffusion,pneumothorax,subcutaneousemphysemaEnhanced:

Consolidationoflungtissue:

lobarpneumonia,pulmonaryinfarction.Largecavityinthelung,esp.nearthepleura:

lungabscess,cavernouspulmonarytuberculosis.

减弱或消失阻塞性肺不张肺气肿胸腔积液气胸皮下气肿增强肺实变:

大叶肺炎肺梗死近胸膜肺空洞:

肺脓肿空洞型肺结核

ClinicalSignificance临床意义Localizedcrackles:

regionaldiseasesBilateralcracklesinlowerfieldofthelungswithrhonchi:

bronchitiswithlunginfection

Cracklesinbilateralbasesofthelungs:

pulmonarycongestioncausedbyheartfailure

Generalizedcoarsecracklesinbilaterallungfields:

acutepulmonaryedema

局部湿啰音:

肺局部炎症两下肺散在干湿啰音:

支气管炎并感染两肺底对称性湿啰音:

左心功能不全两肺满布湿啰音:

急性肺水肿、

Emphysema肺气肿Pathology:

airtrappinginthelungInspection:

barrelchest

Palpation:

decreaseddynamiceventsofrespirationandtactilefremitusPercussion:

hyperresonce;Down-shiftingoftheinferiorborderofthelungAuscultation:

decreasedbreathsoundsandvocalresonance

机制双肺含气增多视诊桶状胸触诊呼吸动度减弱语颤减弱叩诊过清音

肺下界下移听诊呼吸音减弱语音共振减弱

Atelectasis肺不张Pathology:

theairwayisobstructedandthelungholdsnoairInspection:

theaffectedchestwallisflattenedPalpation:

decreaseddynamiceventsofrespirationandtactilefremitus;ThetracheaisshiftedtotheaffectedsidePercussion:

dullnessorflatnessAuscultation:

breathso