病史书写1-朱伟.ppt

病史书写weizhu65@朱伟心内科;A. 一般项目 General Items;B. 主诉Chief complaint;B. 主诉Chief complaint; 全身症状 (General)发热 fever疼痛 pain不适 malaise疲倦 lassitude；fatigue虚弱 weakness；debilitating瘦 wasting； thin；emaciation出汗 sweating；perspiration多汗 hidrosis发冷 feel chilly畏寒 chilly sensations寒战 shivering；shaking chill瘙痒 pruritus痒 itching; A） 呼吸系统：气喘 asthma咳嗽 cough呼吸困难 dyspnea 咯血 hemoptysis喘鸣 wheezing痰 sputum；phlegmB）循环系统：胸痛 chest pain心前区痛 precordial pain；胸骨后痛 retrosternal pain；胸部压榨感（压迫感；窒息感；紧缩感） squeezing ( pressing；choking； tightness) sensation of the chest泡沫样痰 frothy sputum活动后气促 breathlessness of exertion阵发性夜间呼吸困难 paroxysmal nocturnal dyspnea; D） 泌尿系统：无尿 anuria尿浑浊 cloudy urine绞痛 colic浮肿 edema腰痛 lumbodynia；lumbago夜尿 nocturia少尿 oliguria多尿 polyuria排尿中断 interruption E） 造血系统：出血 bleeding皮肤出血点 bleeding spots in the skin鼻出血 epistaxis牙龈出血 gum bleeding术后伤口出血 postoperative wound hemorrhage血尿 hematuria; F）内分泌系统：贪食 hyperorexia矮小 dwarfism过高 excessive height多汗 excessive sweating手抖 hands tremble肥胖 obesity消瘦 wasting烦渴 polydipsia；excessive thirstG）生殖系统：月经不调 menoxenia月经过多过频 epimenorrhagia月经过频 epimenorrhea；polymenorrhea月经过少 hypomenorrhea（指量）； oligomenorrhea(间隔长)月经过多 menorrhagia；闭经 amenorrhea；绝经 menostasis；menopause; H）神经系统：焦虑不安 agitation忧虑 anxiety失语 aphasia健忘 amnesia；头晕 dizziness倦睡 drowsiness蚁走感 formication偏身麻木 hemianesthesia半身不遂 hemiplegia失眠 insomnia麻木 numbness眩晕 vertigo昏倒 syncope麻刺感 tingling游走痛 wandering pain; i)运动系统：关节痛 arthrodynia；arthralgia背痛 back pain腰痛 lumbago；lurnbodynia足痛 foot pain肢痛 pain in limbs；acrodyniaj)皮肤科症状抓痒后渗血 blood oozed out after scratch an itch渗出 exudation头皮屑 scurf肿 swollen; 耳疾病聋 deafness；anacousia耳痛 otalgia；otodynia耳鸣 tinnitus头晕 vertigo鼻疾病鼻干燥 dryness of the nose嗅觉丧失 anosmia嗅觉减退 hyposmia额部头痛 frontal headache鼻塞 nasal obstruction脓鼻涕