14 Heart:
Inspection: P.M.I. ( point of maximal impulse ) 心尖搏动点, abnormal pulsation
of retraction 回缩.
Palpation: location of P.M.I., thrills 震颤, pulse rate , rhythm, vessel
wall, etc.
Percussion: right and left borders of heart.
Auscultation ( heart sounds ): intensity, loud, accentuated 加重,exaggerated
过大, soft, faint 微弱, diminished / decreased, absent, disappeared; M1, A2,
P2, character of cardiac rhythm, murmur杂音, time: pre-(mid-, post-)
systolic 收缩期, pre-(mid-, post-) diastolic 舒张期; location, pitch 顶点,
character: blowing, loud, soft, rough or harsh, clubbing 杵状指,scratching
擦刮声, pouring倒水声, rustling 沙沙声, whistling 哨声, lapping 舔食声.
15 Abdomen:
Inspection(Naked) : contour 外形, scars, dilated veins 静脉怒张, visible
peristalsis 肠蠕动, striate character of wall 腹纹, abnormal pigmentation.
Palpation: distension 膨胀度, gurgling 气过水声, ebound tenderness 反弹性,tenderness
in costovertebral areas 肋脊角, tenderness over McBurney's point; masses:
size, shape , consistency, fixed or movable; location: epigastric上腹,
hypogastric 下腹, hypochondriac 右季肋部, or iliac region 髂部;shape and
consistency 致密度 of liver, kidney, or other palpable organs: elastic, hard,
dull, sharp.
Percussion: shifting dullness 移动性浊音, ascites 腹水, fluid wave 液波,meteorism
鼓胀, tympani 气胀, liver, spleen 脾, other dullness.
16 Genitalia:
Male: pubic hair 阴毛, development of external genitalia, urethral
discharge, prepuce 包皮, scrotum 阴囊, testes / testicle 睾丸, penile lesions
**损伤or scars , hydrocele 阴囊积液, testicular atrophy or masses, spermatic
cords 精索, absence or presence of secondary *** characteristics.
Female: pelvic 盆腔 examination: inspection of external genitalia, vagina
**, hymen 处女膜 intact 完整 or not, introitus 入口, discharge, rectocele 直肠凸出,
cystocele 膀胱凸出. inspection perineum 会阴, cervix 宫颈: color, position,
lacerations 撕裂伤, erosions 糜烂, eversions外翻. bimanual examination 双合诊of
uterus 子宫 and adnexa 附件.
17 Back:
curvatures, symmetry, mobility, tenderness over spine 脊柱, pelvis, and
kidney.
18 Extremities 四肢:
wasting 消瘦, muscle tone 肌张力, masses, wounds,
Upper: hands, color and moisture of palms, clubbed fingers, cyanosis 紫绀 of
nails, joint swelling or deformity, shoulder, elbow, upper arm, fore arm.
Lower: mobility or deformity of joints, color and temperature of feet,
edema, varicose veins下肢静脉曲张 , leg length, thigh 大腿, thigh circumference
(upper 1/3, mid 1/3, lower 1/3); knee, calf 小腿肚子, foot(ankle, instep 足弓 or
dorsum 足背, sole 足底, heel 足跟).
19 Neuropsychiatric examination:
Cranial nerves 颅神经.
Motor functions: weakness, palsy 麻痹, hemiplegia 偏瘫, paraplegia
截瘫,mono-plegia 单瘫, spasticity 强直, flaccidity 松弛, Incoordination 共济失调, gait
and station.
Deep tendon reflex 深腱反射: biceps, triceps, patellar, Achilles
跟腱反射,Babinski, Kernig, degree of activity (+ to +++), compare right and
left.
Sensory functions: vibration 震动, pain, heat, cold and position, the five
senses: sense of hearing, sight, taste, touch, smell.
1 腹部平软, 肝脾未及, 无压痛,未扪及胞块.
双下肢轻度凹陷性水肿,无移动性浊音。四肢活动正常,深腱反射正常。颈软,克氏征(--),巴氏征(--)。
RBC 3.61X10/L,WBC 182X10/L,PL 7.3X10/L。出、凝血时间均正常。
骨髓检查为:急性淋巴性白血病。
Abdomen was flat and soft. Liver and spleen impalpable without tenderness.
No masses on palpation. Mild pitting edema on both legs. No shifting
dullness. Movement of upper and lower extremities normal. Deep tendon
reflex normal. Neck: supple. Kernig's sign and Babinski's sign both
negatives.
RBC: 3.61x10 /L, WBC: 182x10/L, PL7.3x10/L. Bleeding and clotting both
normal.
Bone marrow examination: acute lymphocytic leukemia.
2 T 38.6℃ P 88 /min R 182 /min BP 17.3/10.7kPa(130/80mmHg)
病人慢性重症病容,神清合作,发育正常,营养中等,表情淡漠,轻度贫血貌。全身散在瘀点,下肢为甚。无黄疸。左眼球重度充血。口唇有少量血痂。气管居中,甲状腺不大。左颌下淋巴节可触到7-8个蚕豆大小,质硬,活动度好。胸廓对等,胸骨有明显压痛和叩击痛。两肺叩诊未见异常。心浊音界未见异常,心率88次/分,律齐,心尖部闻及Ⅲ-Ⅵ级收缩期吹风样杂音。双肺清晰,未闻及干、湿鸣,触觉震颤双侧对等,无明显增强、减弱。
T 38.6℃ P 88 /min R 182 /min BP 17.3/10.7kPa(130/80mmHg)
The patient appeared chronically severely ill, alert and cooperated, well
developed and moderately nourishes with mildly pallory face. Scattered
petechiae were seen all over the skin, especially on both legs. No
jaundice on sclera, but severe injection in the left eyes ball. Small
amount of blood crust on the lips and gums. Trachea midline. Thyroid not
enlarged. Submacxillary lymphernode on the left, been-sized, 7-8 in number
were palpable. They were hard, freely mobile and without tenderness. Chest
was symmetrical with equal respiratory movement. At the stemum, there was
obvious tenderness. Both lungs normal to percussion. Dullness of heart
border normal. Rhythm regular at 88 / min. 3 / 6 blowing systolic murmur
was heard at the apex. Both lungs clear auscultation. No dry or moist
rales. The fremitus equal bilaterally was neither exaggerated nor
diminished.
Ⅳ Laboratory Data and X-ray Data
1,.心电图示: 电轴左偏, 可能有左室肥大, 伴有陈旧性前臂心肌梗塞。
E.C.G. revealed left deviation axis and probably left ventricular
hypertrophy complicated with pattern of an old anterior wall myocardial
infarction.
2。胸部X线显示:广泛性的肺间质纤维化,双侧整个肺叶充满蜂窝状改变,双肺有散在的密度增高影,可能代表浸润。
The chest X-ray revealed extensive lung interstitial fibrosis and
bilateral lung fields full of honeycombing change. The official reading
was that there was scattered densities shadow increasing throughout both
lung fields, which possibly represent supraimposed infiltrates.
3.胸部X线检查显示:心脏显著一致性增大,慢性充血性改变,可能伴有右肺中叶近内侧面液体聚积。.
The chest X-ray examination revealed a marked generalized cardiac
enlargement and chronic conjestive changes with a possible location of
fluid near the right medial aspect of the right middle lobe.
4.进行钡剂灌肠检查,整个结肠为钡剂充填,无充盈迟延式梗阻,回肠末端清楚可见,无外来肿块压迫,未观察到充盈性缺损,映象正常结肠。
Barium Enema Examination of the colon was made by neoms of a barium enema.
The entire colon was filled with barium without evidence of delayed in
foklling of obstruction. The eterminal ileam was well visualized. The
large bowel was normal in position without evidence of extrinsic mass of
pressure. No filling defect of the colon was observed. Impression: Normal
colon.
5 我们746例冠心病患者及12例作为对照的正常人进行了心肌201铊灌注闪烁照相检查。 Thallium-201 myocardial perfusion scintigraghy was performed in 46 coronary patients and 12 normal
controls.