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    英文病历书写手册第七章:体检(头颈部)

       作者:古龙   2009-07-04
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            第七章  体检(头颈部)[Physical examination(head and neck)]

            1、头颅[cranium,skull]
           •头颅变形[deforming skull]
           •头形(围)[head contour (circumference)]
           •小颅(尖颅,巨颅)[microcephalism (acrocephalia,large skull)]
           •长(短)头[dolichocephalia (brachycephalism)]
           •方(塔)颅[squared (tower) skull]
           •落日现象[sitting sun phenomenon]
           •颅缝[cranial suture]
           •前(后)囟门[anterior (posterior) fontanel]
           •囟门膨出(塌陷)[bulging (edpressed) fontanel]
           •囟门晚(早)闭[delayded (earlier) closure of the fontanel]
           2、眼球[eyeball]
           •眼球浮动[ocular bobbing]
           •眼球破裂[eyeball rupture]
           •眼球穿孔伤[ocular-perforating injury]
           •眼球内异物[intralcular foreign body]
           •眼距增宽(变窄)[ocular hypertelorism (hypotelorism)]
           •眼球萎缩[atrophy of eyeball]
           •眼球突出(凹陷)[exophthalmos (enophthalmos)]
           •眼球震颤[nystagmus]医学全.在线提供
           •眼球固定[eyeball fixation (stare)]
           •眼球活动受限[limitation of eye movement]
           •假眼[ocular prosthesis]
           •眼外肌运动[extraocular movements]
           3、眼睑[eyelids]
           •睑内(外)翻[entropion (ectropion)]
           •流泪[lacrimation]
           •上睑下垂[ptosis]
           •眼睑痉挛(松驰)[blepharospasm (blepharo-chalasis)]
           •眼睑水肿(红肿)[edema (redness and swelling) of the eyelids]
           •瞬目过少[nictitation diminution(lid lag )]
           •瞬目过多[frequent nictitation (blinking)]
           •眼裂缩小(增宽)[blepharophimosis (blepharodia stasis)]
           •眼睑充血[blepharal hyperemia]
           •泪囊[lacrimal sac ]
           •睫毛反射[eyelash reflexes]
           •压眶反射[reaction to pressure on the supraocular notch]
           •皱眉(皱额,闭目)[raise eyebrows (wrinkle forehead,force eyelids closing)]
           4、结膜[conjunctive]
           •结膜反射[conjunctival reflexes]
           •充血[congestion]
           •红(白)[redness (pallor)]
           •球结膜水肿[chemosis]
           •结膜滤泡(滤泡增生)[conjunctival follicle (folliculosis)]
           •沙眼[trachoma]
           •胬肉[pterygium]
           •水样(脓性)分泌物[watery (purulent) discharge]
           5、角膜和巩膜[cornea and sclerae]
           •角膜反射[corneal reflexes]
           •角膜混浊[cornea opacity]
           •透明(不透明)的[transparent (opaque)]
           •异物[foreign body]
           •老年环[arcus senilis]
           •溃疡(穿孔)[ulcer (perferation)]
           •黄染(无黄染)[stained yellow (anicteric)]
           6、瞳孔[pupil]
           •右眼[OD (oculus dextet)]
           •左眼[OS (oculus sinister)]
           •2mm大小[2mm in size]
           •等大等园[be equal and round ]
           •瞳孔大小不一[unevenness of pupils (anisocoria)]
           •固定[fixed]医.学.全.在线.网.站.提供
           •瞳孔缩小[contraction of pupils (miosis)]
           •瞳孔散大[dilation of pupils (platycoria)]
           •瞳孔畸形(闭锁)[deformity (seclusion) of pupils]
           •直接(间接)对光反射[direct (consensual) response to light]
           •瞳孔对光反射(佳)(差)[good (poor) light reflex of pupils]
           •对光反射存在[retain light reflexes]
           •调节反射[accommodation reflex]
           •辐辏反射[convergence reflex]
           7、视力和视野[Vision and Visual fields]
           •视力模糊(减退,差)[blurred (impaired, poor) Vision]
           •弱视[amblyopia]
           •复视[double vision (diplopia)]
           •斜视[strabismus]
           •麻痹性斜视[paralytic squint]
           •偏盲[hemiscotosis]
           •失明[amaurosis (blindness)]
           •夜盲[night blindness]
           •色盲[color blindness]
           •全色盲[achromatopsia]
           •绿(蓝)色盲[achromatopsia green(blue) blindness]
           •红-绿色盲[red-green blindness]
           •色弱[color weakness]
           •远视[far-sightedness (far –sighted,hyeropia)]
           •近视[short-sightedness (short-sighted,nearsightedness,myopia)]
           •右(左)眼200度[200 degree,OD(OS)]
           •左(右)眼视力[OS(OD) vision]
           •视野完整[full (intact) visual fields]
           •象限视野缺损[tetarfanopia]
           •单侧(双颞侧)缺损[unilateral (bitemporal) defect]
           •视野缺损[visual field defect]
           •视野缩小[contraction of visual field]
           8、眼底和眼压[fundus and intraocular pressure]
           •眼底镜检查[fundoscopy (ophthalmoscopy)]
           •眼底清晰[fundi are clear]
           •小动脉(小静脉)[arteriole (venule)]
           •小动脉狭窄[narrow arteriole]
           •小动脉硬化[arteriolosclerosis]
           •微动脉瘤[microaneurysm]
           •动静脉压迹[A-V nicking]
           •点状(头焰样)出血[punctate (flame) hemorrhage]
           •视乳头色素沉着[pigmentation of disc (retina)]
           •视神经乳头(视神经)水肿[papilledema (papilloedema)]
           •视乳头凹陷(苍白)[excavation (pallor) of optic disc]
           •视网膜出血(水肿,渗出)[retinal hemorrhage (edema,exudation)]
           •视网膜色素变性[pigmentary degeneration of retina]
           •视网膜剥离[retinodialysis]
           •视网膜变性(损伤)[retinal degeneration (injury)]
           •测眼压[intraocular pressure measurement]
           •眼压升高(降低)[increase (decrease) of intraocular pressure]
           9、耳廓和外耳道[pinna and external canal]
           •红(肿、痛,压痛)[redness (swelling,pain,tenderness)]
           •糜烂(渗出物,脓性分泌物)[erosion (exudate,purulent discharge)]
           •疱疹(瘘管,小水疱,血疱)[herpes (fistula,visicle,blood blisters)]
           •狭窄(闭锁)[stenosis (clausura)]
           •耵聍(耵聍栓塞,耵聍过多)[cerumen (ceruminal impaction,ceruminosis)]
           •耳疖[furuncle of ear ]
           •耳化脓(溢脓)[otopyosis (otopyorrhea)]
           •耳廓假性囊肿[pseudocyst of auricle]
           •外耳道异物[foreign body of external auditory canal]
           •耵聍钩(钳)[cerumen hook (forceps)]
           10、鼓膜[tympanic membrane (drum)]
           •光反射[light reflex]
           •红色(粉红色,苍白)[be red (pink,pale)]
           •鼓膜内陷[otopiesis (indrawing of drum)]
           •鼓膜膨出[umbo (bulge of drum)]
           •鼓膜穿孔(粘连)[perforation (adherence) of drum]
           •中央(周围)性穿孔[central (marginal) perforation]
           •鼓膜破裂[myringorupture]
           •鼓膜增厚(充血,疤痕,疱疹,肉芽)[hypertrophy (congestation,scar,herpes,granulation) of drum]
           •鼓室积水(血)[hydrotympanum (hematotympanum)]
           11、听力[audition (hearing)]
           •听觉过敏(减退)[hyperacusis (hypoacusis)]
           •听觉不良(迟钝,障碍)[dysacousis (bradyacusia, dysacusis)]
           •听觉域[auditory sensation area]
           •听力正常[normal hearing]
           •听力(觉)迟钝[auditus depression (amblyacousia)]
           •听力障碍[dysaudia]
           •听力丧失[hearing loss (disability)]
           •传导性(神经性,感音神经性)耳聋[conductive (neural,sensorineural) deafness]
           •老年性耳聋[presbycusis]
           •音叉试验[tuning fork test]
           •秒表(耳语)听力检查[stopwatch (whisper) audiometry]
           •韦伯氏试验(骨导偏向试验)[Weber’s test]
           •任内氏试验(气骨导听力比较试验)[Rinne’s test]
           •施瓦巴赫氏试验(骨导对比试验)[Schwabach’s test]
           12、鼻[nose]医学.全.在线.网.站.提供
           •酒渣鼻[rosacea]
           •鞍(蛙状)鼻[saddle(frog) nose]
           •畸形(肿胀,溃疡)[deformity (swelling,ulcer)]
           •鼻翼扇动[flaring (movement) of alae nasi (nasal ala flap)]
           •鼻骨骨折[fracture of nasal bone]
           •鼻疖[nasal furuncle]
           •鼻道狭窄[rhinostenosis (stenosis of nasal canal)]
           •流涕[running nose]
           •鼻粘膜干燥(苍白,红)[dry (pale,red ) mucosa]
           •鼻腔异物[nasal foreign body]
           •鼻粘膜萎缩(肥厚,肿胀)[nasal mucosa atrophy (hypertrophy,swelling)]
           •鼻孔(甲)[naris (turbinates)]
           •上(中、下)鼻甲[superior (middle,inferior ) turbinates]
           •鼻塞[nasal obstruction]
           •鼻中隔偏移(穿孔,肿胀,血肿,溃疡)[deviation (perforation,swelling,hematoma,ulcer) of nasal septum]
           •鼻(副鼻)窦[nasal (paranasal) sinus]
           •额(上颌,蝶,筛)窦[frontal (maxillary,sphenoid,ethmoid) sinus]
           •鼻窦压痛[tenderness over sinuses]
           •鼻镜检查[rhinoscopy]
           13、嗅觉[smell (scent)]
           •嗅觉减退(敏锐)[hyposmia (oxyosmia)]
           •嗅觉异常[heterosmia]
           •嗅觉测定[measurement of olfaction]
           •嗅觉倒错(嗅幻觉)[paraosmia (olfactory hallucination]
           •嗅觉缺失[anosmia]
           14、口腔粘膜与唇[mucosa of mouth and lips]
           •口腔(唇)[oral cavity (lips)]
           •口瘢痕挛缩[cicatricial contracture of mouth]
           •口疮[aphtha]
           •口角[angle of mouth]
           •唇(口角)干裂[cheilosis (angular cheilosis)]
           •皱裂[ehagades]
           •口裂[oral fissure]
           •干燥(湿润)[dry (moist)]
           •口唇干燥[xerocheilia (desiccation fissure)]
           •口臭[halitosis (ozostomia)]
           •口唇(腔)疱疹[herpes labialis (of mouth)]
           •口唇肥厚[lips pachynsis]
           •口角糜烂[perleche]
           •口腔坏疽[oral gangrene]
           •柯泼力克氏斑[Koplik’s spots]
           •口腔白斑(溃疡形成)[oral leukoplakia (ulceration)]
           •口水(口涎增多)[saliva (ptyalism)]
           •口周苍白(雀斑)[circum-oral pallor (freckle)]
           •闭口困难[open bite (closure lips irreducible)]
           •张口受阻(困难)[limitation (difficulty) of mouth opening]
           15、牙齿[tooth]
           •牙表面[tooth surface]
           •牙不齐[odontoloxy (alignment disorder,malalignment)]
           •牙发育不全(异常)[metodontiasis (dysplasia dentalis)]
           •牙根折断[dental root fracture]
           •牙齿缺失[anodontia (absence of the tooth)]
           •牙脱落[odontoptosis (lose a tooth)]
           •缺齿[missing teeth]
           •残根[residual root]
           •牙松动[odontoseisis (loosening of the tooth)]
           •牙垫[bite-block]
           •牙磨损[tooth abrasion]
           •牙骨质增生[hypercementosis]
           •牙冠破裂[cracking of crown]
           •牙石[odontolith (tartar,dental calculus)]
           •牙列拥挤[crowded dentition]
           •牙缝宽[wide interdental space]
           •牙萌出过迟(早)[delayed (premature) eruption of tooth]
           •牙线[dental floss]
           •牙髓腔(炎)[pulp cavity (pulpitis)]
           •拔牙[extract (pull out ,draw out,put out) a tooth]
           •假牙[false (artificial tooth)]
           •假牙[prosthesis]
           •镶牙[insert tooth]
           •龋齿[decayed teeth (dental caries)]
           •龋洞[carious cavity]
           •牙面色素沉着[pigmentation of tooth surface]
           •牙关紧闭[trismus (lockjaw)]
           •牙触(叩击)痛[tooth tenderness (percussion pain)]
           •牙周囊肿(感染,萎缩)[periodontal cyst (infection,atrophy)]
           16、牙龈[gum (gingiva)]医学全.在线网.站.提供
           •牙龈出血(囊肿,坏疽,撕裂)[gingival bleeding (cyst,gangrene,laceration)]
           •牙龈充血(肿胀,糜烂)[gingival engorgement (swelling,erosion)]
           •牙龈萎缩(增生)[gingival atropy (hyperplasia)]
           •牙龈(牙周)溢脓[gingival pyorrhea (peripyema)]
           •牙龈脓肿[gumboil]
           17、舌[tongue]
           •舌背静脉[dorsal lingual veins]
           •舌颤动[tremulous tongue (lingual tremor)]
           •舌淀粉样变性[amyloid degeneration of tongue]
           •舌后坠[glossocoma]
           •舌尖麻木[tongue tip numbness]
           •舌裂[split tongue]
           •舌脓肿(溃疡)[tongue abscess (ulcer)]
           •舌乳头(体,背)[papillae (body, dorsum) of tongue]
           •舌苔[coated (furred) tongue]
           •地图(草莓,镜面)舌[geographic (strawberry, marror face) tongue]
           •裂纹(牛肉)舌[wrinkled (beefy) tongue]
           •毛舌[hairy tongue]
           •舌光滑(粗糙)[smooth (rough) tongue]
           •舌滤泡[lingual follicles]
           •舌干燥[sausarism]
           •舌肌萎缩(肥厚)[atrophy (hypertrophy) of tongue muscle]
           •舌系带过短[tongue tie (ankyloglossia)]
           •舌下囊肿(溃疡,脓肿,肿块)[sublingnal cyst (ulcer, abscess, tumor)]
           •伸舌困难(偏斜)[difficulty (deviation) of tongue extenison movement]
           18、咽和扁桃体[pharynx and tonsil]
           •鼻(口)咽[nasal (oral) pharynx]
           •扁桃体不肿大[no enlargement of tonsil]
           •无充血和渗出[no injection (congestion) and exudate]
           •脓点(滤泡,白色小点)[beads of pus (follicle, white particle)]
           •扁桃体出血(感染,肥大,溃疡)[hemorrhage (infection, hypertrophy, ulcer) of tonsil]
           •扁桃体肿大[swelling of tonsil]
           •扁桃体(后,周围)脓肿[tonsillar (retrotonsillar, peritonsillar) abscess]
           •扁桃体缺如[tonsil deletion]
           •扁桃体隐窝(窝)[tonsillar crypts (fossa)]
           •咽部异物(溃疡,分泌物)[pharyneal foreign body (ulcer, secretion)]
           •咽后壁淋巴滤泡增生[retropharyneal folliculosis]
           •咽部干燥(疱疹,充血,水肿)[dryness (herpes, congestion, swelling) of throat]
           •咽反射[pharynx reflex]
           •咽下不能[dysphagia]
           •腮腺肿大[enlargement of parotid gland]
           19、喉[larynx]
           •白喉(喉白斑)[diphtheritic croup (leukoplakia of larynx)]
           •喉闭锁[atretolemia]
           •喉梗阻[laryngemphraxis (laryngeal obstruction)]
           •喉痉挛(狭窄)[laryngeal spasm(laryngo-stenosis)]
           •喉头痉挛[laryngospasm]
           •喉反射[laryngeal reflex]
           •喉坏死(钙化)[necrosis (calcification)of larynx]
           •喉瘘(囊肿,脓肿,息肉,血肿,异物)[laryngeal fistula(cyst,abscess,polyp,hematoma,foreign body)]
           •喉膨出[laryngocele]
           •喉缺失[absence of largnx]
           •喉头水肿[laryngeal edema]
           •声嘶(哑)[hoarseness (dumbness)]
           •变(失)声[mutation (loss) of voice]
           •失音[aphonia]
           •发音(构音)障碍[pararthria (dysarthria)]
           •喉部感觉缺失[laryngeal anesthesia]
           •会厌发育不全(擦伤,裂,囊肿,脓肿)[agenesis (abrasion, fissure, cyst, abscess) of epiglottis]
           •会厌分叉(结节)[bifid epiglottis(epiglottic tubercle)]
           •声带肥厚[hypertrophy of vocal cords]
           •声带麻痹[vocal cord paralysis]
           •声带小结[vocal nodule]
           •声带息肉[polyp of vocal cord]
           •声门痉挛[glottis spasm]
           •声门下狭窄[subglottic stenosis]
           20、颈部[neck]
           •颈部创伤[neck trauma]
           •颈部淋巴结(囊肿)[cervical lymph node (cyst)]
           •颈动脉窦按摩[carotid sinus massage]
           •颈强直[neck rigidity (stiff-neck rigidity, stiff neck)]
           •颈软[soft neck (supple)]
           •斜颈[torticollis]
           •角弓反张[opisthotonus]
           •颈静脉搏动(曲张)[jugular pulse (varicosity)]
           •颈静脉怒张[jugular vein distention (JVD)]
           •颈静脉充盈(怒张)[jugular vein is full(distention and prominence)]
           •库斯毛氏征[Kussmaul`s sign]
           •肝颈反流[hepatojugular reflex]
           •收缩期(舒张期)囊颤[systolic (diastolic) thrill]
           •颈动脉搏动异常(增强、减弱、消失)[abnormal carotid pulsation (increase, decrease, disappearance)]
           21、甲状腺[thyroid]
           •弥漫(局灶,结节)性甲状腺肿大[diffuse (local, nodular) thyroid enlargement]
           •甲状腺震颤[thyroid tremor]
           •震颤[thrill]
           •甲状腺血管杂音[thyroid vascular murmur]
           •甲状腺峡部[isthmus of thyroid gland]
           •甲状旁腺[parathyroid gland]
           •甲状腺囊肿(滤泡、肿块,出血)[thyroid cyst (follicle, tumor, hemorrhage)]
           22、气管[trachea]
           •气管插管[endotracheal intubation]
           •气管痉挛[tracheospasm]
           •气管囊肿(息肉、狭窄、移位)[tracheal cyst (polyp, stenosis ,displacement)]
           •气管(向右)偏移[displacement of trachea (tracheal deviation to the right)]
           •气管居中[trachea is in the midline]
           •气管内异物[intratracheal foreign body]
           来源:医学全在线

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