病史书写.pptVIP

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病史书写

B. 眼 Eye 色觉 color perception: He has red and green color blindness He has a color weakness The intraocular pressure ,30 mm Hg,OD;20mmHg, OS C. 耳 Ear 鼓膜 drum;tympanic membrane: 视力模糊: blurred vision;eye-blurred 膨出: Bulge 发红的: flushed 内陷: Indrawing 穿孔: perforation 中央性穿孔: central perforation 边缘性穿孔: marginal perforation C. 耳 Ear 听力 hearing: 听觉迟顿: amblyacousia;baryacusia 听觉减退: hearing loss 传导性耳聋: conductive deafness He could hear conversational Voice only within a distance of a meter on the right side. Hearing tests confirm the presence of conductive deafness D. 鼻 Nose 1. The examination reveals a saddle deformity of the nose 2. There is a shallow ulcer (l. 5 by 1 cm) with a raised border on the nasal apex 3. The mucosa and turbinates are within normal limits. D. 鼻 Nose 4. The nasal mucasa is red and swollen, and the cavity contains watery secretion 5. Rhinoscopy shows a pinkish soft friable mass, which bleeds easily on touch, arising from the middle meatus of the left nose 6. Posterior rhinoscopy shows a smooth, greyish-white, spherical mass in the choana D. 鼻 Nose 嗅觉 Smell;Scent: 嗅觉缺失; anosmia 嗅觉迟顿; baryodmia 嗅觉敏锐: oxyosphresia Anterior rhinoscopy reveals the septum is markedly (acutely) deviated to the left. Posterior rhinoscopy shows mucopus on the superior surface of the soft palate. There is tenderness over the frontal sinuses E. 口腔与咽 Mouth and pharynx 粘膜与口唇 Smell;Scent: 唇干裂: Cheilosis 口臭: halitosis 口唇疱疹: herpes labials Some white plaques are on the oral mucosa, the plaque is scraped off with difficulty, exposing a red base. E. 口腔与咽 Mouth and pharynx 牙齿 tooth: 牙齿磨损; attrition of the tooth 龋齿: dental caries (decayed teeth 假牙: false teeth 镶牙: insert teeth 牙齿松动: loosening of the tooth 牙齿脱落: lose a tooth 牙髓炎: pulpitis 牙石: tartar (dental calculus) 牙关紧闭: trismus; clenching of the teeth His 2nd molar is decayed tooth E. 口腔与咽 Mouth and pharynx 舌 tongue: 舌苔: coated tongue, furred tongue 地图舌: geographic tongue 舌面光滑: smooth tongue

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