第一篇：英文病例范本
Note for Jane Doe on 4/8/03Electronic Medical Records
Dr.Dermatology, MD
DEA#:
_____________________________________________________________
Name: Jane DoeDate: 4/8/03
Addr: 1231 8th Street, Suite 222
West Des Moines , IA 50265
_____________________________________________________________
Tetracycline
250 mg capsule
BID
X_____________________________________ X_____________________________________ Substitution PermittedDispense as written
Refills: 0
Disp: 60
Allow Generic: Yes
Sample Referral Letter
Charting Plus™Electronic Medical Records
Patient Instructions for Jane Doe on 04/11/2002
ACNE VULGARIS
What is it?
Acne vulgaris, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life.The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.Signs and symptoms:
* Blackheads the size of a pinhead.* Whiteheads similar to blackheads.* Pustuleslarge, firm swollen lesions in severe acne.* Abscess-infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.Causes:
Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role.When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection.Acne is NOT caused by foods, uncleanliness or masturbation.Cleaning the skin can decrease its severity but sexual activity has no effect on it.A family history of acne can indicate if an individual will get acne and how severe it might be.Currently, acne can´t be prevented.Acne can be brought on or made worse by:
* Hot or cold temperatures.* Emotional stress.* Oily skin.* Endocrine(hormone)disorder.* Drugs such as cortisones, male hormones, or oral contraceptives.* Some cosmetics.* Food sensitivities.Again, foods do not cause acne but some certain ones may make it worse.To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time.If acne worsens 2-3 days after consumption, then avoid this food.Acne usually improves in summer so some foods may be tolerated in summer that can´t be eaten in winter.Treatment:
* Most cases of acne respond well to treatment and will likely disappear once adolescence is over.Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.* If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3-5 minutes;an antibacterial soap may work better.A pre viously used wet washcloth will harbor bacteria.Don´t aggressively scrub tender lesions as this may spread infection;be gentle.Rinse the soap off for a good 1-2 minutes.Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.Other tips that may help acne:
* Shampoo hair at least twice a week.Keep hair off of face even while sleeping as hair can spread oil and bacteria.If you have dandruff, use a dandruff shampoo.Avoid cream hair rinses.* Wash sweat and skin oil off as soon as possible after sweating and exercising.* Use thinner, water-based cosmetics instead of the heavier oil-based ones.* Avoid skin moisturizers unless recommended by your doctor.* Do not squeeze, pick, rub or scratch your skin or the acne lesions.This may damage the skin
causing scarring and delay healing of acne.Only a doctor should remove blackheads.* Keep from resting face on hands while reading, studying or watching TV.* Try to avoid pressing the phone receiver on you chin while talking on the phone.* Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe!Don´t use the sun to treat acne.* Dermabrasion may be another option to treat acne scars.This is a type of cosmetic surgery to help remove unsightly scars.Medications that may be prescribed to help acne include:
* Oral or topical antibiotics.* Cortisone injections into acne lesions.* Oral contraceptives.* Tretinoin, which may increase sun sensitivity and excessive dryness, is not recommended during pregnancy.*Accutane(isotretinoin)is a powerful drug to treat acne but causes birth defects.A woman taking this drug must be on two types of birth control and have negative pregnancy tests.This drug also increases sun sensitivity.Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.TETRACYCLINE
Your doctor has prescribed Tetracycline for your condition.Tetracycline is a very safe antibiotic.It is not related to penicillin and an allergy to it is unusual.There are several potential side effects:
1.Tetracycline can cause nausea or heartburn.2.Tetracycline can cause vaginitis.3.Tetracycline can cause excessive sun burn.CAUTIONS:
1.Do not take Tetracycline with milk or milk products(ice cream, cheese, yogurt, etc.).This will cancel out the Tetracycline.Separate the Tetracycline from these products by one and one-half hours before and after each capsule.Do have a small amount of non milk-containing food in your stomach first to prevent nausea.2.Do not take Tetracycline if you are pregnant.3.Do not take Tetracycline if you are taking birth control pills unless specifically instructed to do so.4.If at the beach or skiing in the sun, use an effective sunblock(SPF-15 or greater)to prevent burning.If problems or questions arise, call the office for assistance.Side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed._______________________________A.Dermatologist, MD
第二篇：英文病例对照
住院病历的英汉对照
分享 宋丽秀 21:06分享
随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！
POMR(Problem-Oriented Medical Records)表格式住院病历 Biographical data: 一般项目：
Name Age Sex Marital status Nativity Race 姓名 年龄 性别 婚否 籍贯 民族
Occupation Date of admission Informant
History 职业 入院日期 病史叙述者 病史 Chief complaint 主诉
History of present
illness 现病史
Past
history 既往史：
Previous health status: well ordinary bad
Infectious diseases平素健康状况： 良好 一般 较差 传染病史
Immunizations Allergies: N Y
clinical manifestation 预防接种史 过敏史 无 有 临床表现 allergen: Trauma: Surgery: 过敏原 外伤史 手术史
Review of systems:(Tick if positive, cross out if negative.If postive, you should write down your disease history and brief course of diagnose and therapy)系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过)Respiratory system: 呼吸系统
Sore throat chronic cough sputum hemoptysis wheezing 咽痛 慢性咳嗽 咳痰 咯血 哮喘 dyspnea chest pain 呼吸困难 胸痛
cadiovascular system: 循环系统
Palpitation dyspnea on exertion hemoptysis syncope 心悸 活动后气促 咯血 晕厥
edema of lower limbs precordial pain hypertention 下肢水肿 心前区疼痛 高血压 Digestive system: 消化系统
Anorexia sour regurgitation belching nausea vomitting 食欲减退 反酸 嗳气 恶心 呕吐
abdominal distention abdominal pain constipation diarrhea 腹胀 腹痛 便秘 腹泻
hematemesis melena hematochezia jaundice 呕血 黑便 便血 黄疸 Urinary system: 泌尿系统
Lumbago frequent micturition urgent micturition urodynia 腰痛 尿频 尿急 尿痛
dysuria hematuria nocturia polyuria oliguria facial edema 排尿困难 血尿 夜尿 多尿 少尿 面部水肿 Hematopoietic system 造血系统
Fatigue dizziness blurred vision gingival bleedig 乏力 头昏 牙龈出血
subcutaneous hemorrhage ostealgia epistaxis 皮下出血 骨痛 鼻衄
Metabolic and endocrine system: 代谢及内分泌系统
Excessive appetite anorexia sweats cold intolerance 食欲亢进 食欲减退 多汗 畏寒
polydipsia tremor hands change of character obvious obesity 多饮 双手震颤 性格改变 显著肥胖
emaciation hirsutism hair losing pigmentation 消瘦 多毛 毛发脱落 色素沉着
chang of sexual function amenorrhea 性功能改变 闭经
Musculoskeletal system 肌肉骨骼系统
Floating arthralgia arthraliga swelling of joints 游走性关节痛 关节痛 关节红肿
deformiteies of jionts myalgia atrophy of muscle 关节变形 肌肉痛 肌肉萎缩
Nervous system 神经系统
Dizziness headache vertigo syncope degeneration of memory 头昏 头痛 眩晕 晕厥 记忆力减退
visual disturbance insomnia disturbance of consciousness 视力障碍 失眠 意识障碍
tremor spasm paralysis paresthesia 颤动 抽搐 瘫痪 感觉异常
Personal history: 个人史 Birthplace Occupation sexual history smoking N Y 出生地 职业 冶游史 吸烟 无 有
about years average pieces per day ceased for years 约 年平均 支/日 戒烟 年
alcohol intake N occasional frequent about years 嗜酒 无 偶有 经常 约为 年 average ml per day others 平均 ml/日 其他
Marital history: 婚姻史：
Marrying age companion’s state of health 结婚年龄 配偶健康状况 Menorrhea and Childbearing: 月经及生育史
Menarche age cycle lasting for days date of last period 初潮 每次持续时间 末次月经时间(age of menopause)绝经年龄
Amount of flow: little normal large menstrual pain: N Y 经量 少 正常 多 痛经 无 有
cycle: regular irregular pregnancy times natural labor 经期 规则 不规则 妊娠 次 顺产
times abortions times premature delivery times 胎 流产 胎 早产 胎
stillbirths times difficult labor and its condition 死产 胎 难产及病情
Familly history(pay attention to the congenital diseases and
communicable diseases and communicable dieases related to the paitent 家族史（注意与患者现病有关的遗传病和传染性疾病）Father: still alive illness died cause of deaths mother:
父：健在 患病 已故 死因 母 still alive illness died cause of death siblings: others: 健在 患病 已故 死因 兄弟姐妹 子女其他
Physical examination体格检查 Vital signs生命体征: Temperature体温
pulse脉搏 /min次/分
respiration呼吸 /min次/分
B.P血压 mmHg General Appearance一般状况: Development发育: ortho-sthenic type正常
asthenic type不良
sthenic type超常 nutrition营养: well良好
fairly中等 poor不良
cachexia恶病质
Facial features面容: normal无病容
acute急性
chronic慢性病容
others其他
Expression表情: natural自知
painful痛苦
anxious忧虑
dreadful恐惧
indifferent淡漠
Position: active semi-recumbent others 体位： 自主 半卧位 其他 Gait: normal abnormal 步态 正常 不正常
Conciousness: aware somnolence confusion stupor coma 神志 清楚 嗜睡 模糊 昏睡 昏迷
delirium coppperatio;well badly 谵妄 配合检查 合作 不合作
Mucocutaneous color: normal red pale cyaosis stainted 皮肤粘膜 色泽 无病容 潮红 苍白 紫绀
yellow pigmentation lesions:N Y(type and distribution)黄染 色素沉着 皮疹 无 有（类型及分布）
Subcutaneous hemorrhange: N Y(type and distribution)皮下出血 无 有（类型及分布）
Hair: normal reduced edema: N Y(position and degree)头发分布 正常 减退 水肿 无 有（部位及程度）
Hepatic palm: N Y spider angionma:N Y（position numbers）others: 肝掌 无 有 蜘蛛痣 无有(部位 数目)其他 Lymphnodes: 淋巴结
Superficial lymph nodes: non-swelling swelling(position and characteristics)全身淋巴结肿大 无肿大 肿大（部位及特征）Head : cranium : size : normal large small deformity: 头部 头颅 大小 正常 大 小 畸形
N Y(coxycephaly squared skull deforming skull)无 有（尖颅 方颅 变形颅）Others: tenderness mass sunk(position)其他异常：压痛 包块 凹陷（部位）
Eyes eyelid: normal edema ptosis trichiasis conjunctive : 眼睑 正常 水肿 下垂 倒睫 结膜 normal hyperemia edema hemrrhage 正常 充血 水肿 出血
eye ball: normal proptosis depression tremor 眼球 正常 突出 凹陷 震颤
motion dysfunction(left right)运动障碍
Sclera :normal yellow cornea : normal abnormal(left right)巩膜 无黄染 有黄染 角膜 正常 异常（左 右）Pupils: equal roundness same size unequal left cm 瞳孔 等圆 等大 不等 左 cm
reaction to light: normal delay(left right)disappear(left right)对光反射 正常 迟钝（左 右）消失（左 右）Others: 其他
Ears: auricle :normal deformity fistula others(left right)耳 耳廓 正常 畸形 瘘管 其他（左 右）
excretions of external auditory canal: N Y(left right feature)外耳道分泌物 无 有（左 右 性质）
Tenderness of mastoid : N Y audation dysfunction: N Y(left right)乳突压痛 无 有 听力粗试障碍 无 有（左 右）
Nose: shape : normal: abnormal()other abnormalities:N Y 鼻 外形 正常 异常（）其他异常 无 有
Nosalala flap obsruction excretions nasal sinus tenderness: 鼻翼扇动 鼻塞 分泌物 鼻旁窦压痛 N Y(position)无 有（部位）
Mouth lips :red syanosis pale herpes fissure mucosa :normal 口唇 红润 发绀 苍白 疱疹 皲裂 粘膜 正常 abnormal(pale petechia)异常（苍白 出血点）
Opening of parotid gland duct: normal abnormal(swelling 腮腺导管开口 正常 异常（肿胀 suppurative excretions)脓性分泌物）
Tongue:normal abnormal(coverings tremor leaning to left or right)舌 正常 异常（舌苔 伸舌震颤 向左、向右偏斜）Gums: normal swelling pus overflow hemorrhage pigments 牙龈 正常 肿胀 溢脓 出血 色素沉着 lead line tooth:regular edentulous carious teeth 铅线 牙列 齐 缺牙—|— 龋齿—|— Tonsils: pharynx: voice: normal hoarse 扁桃体 咽 声音 正常 嘶哑
Neck:resistence:N Y carotid artery pulsation: normal increased 颈部 抵抗感 无 有 颈动脉搏动 正常 增强
decreased(left right)jugular vein:normal distention 减弱（左 右）颈静脉 正常 充盈
high distention trachea:middle deviation to(left right)怒张 气管 正中 偏移（向左 向右）
Hepatojugular reflux:(-)(+)thyroid: normal swelling degree 肝颈静脉回流征：（-）（+）甲状腺 正常 肿大 度
Symmetry 对称
Dominance in one side: spreading nodular:soft hard others :N Y 侧为主 弥漫性 结节性 质软 质硬 其他 无 有(tenderness tremor bruits)（压痛 震颤 血管杂音）
Chest topography:normal barrel chest pigeon chest funnel chest 胸部 胸廓 正常 桶状胸 鸡胸 漏斗胸 flat chest bulging or retraction(left right)扁平胸 膨隆或凹陷（左 右）
bulging in the precordial region tenderness of sternum 心前区膨隆 胸骨压痛
Breast: normal symmetrical abnormal : left right(gynecomastia 乳房 正常对称 异常 左 右（男乳女化 mass tenderness excretions of nipples)包块 压痛 乳头分泌物）Lung 肺
Inspection : movement of respiration : normal abnormal : left 视诊 呼吸运动 正常 异常 左 right(increased decreased)右（增强 减弱）
Intercostal space :normal wide narrow(position)肋间隙 正常 增宽 变窄（部位）
Palpation : vocal fremitus:normal abnormal :left right(increased 触诊 ： 语颤 正常 异常 左 右（增强
decreased)pluernal friction rubs: N Y（position）减弱 胸膜摩擦感： 无 有（部位）
Subcutaneous crepitus: N Y(posotion)percussion: resonance 皮下捻发感 无 有（部位）叩诊 正常清音 abnormal dullness flatness hyperresonance tympany 异常叩诊音 浊音 实音 过清音 鼓音 Lower borders:scapular line: right intercostal space, left 肺下界 肩胛线 右肋间 左
intercostal space Range of mobility: right cm , left cm 肋间 移动度 右 cm，左 cm Dusculation: breath regular irregular 听诊 呼吸 规整 不规整
Breath sound: normal abnormal(feature, position)呼吸音 正常 异常（性质，部位描写）Rale: N Y ：ronchi: sonorous sibilant 啰音：无 有： 干性 鼾音 哨笛音
Moist rales: coarse medium fine rales crepitus 湿性 大 中 小水泡音 捻发音
Vocal conduction: normal abnormal: reduced increased(position)语音传导 正常 异常 减弱 增强（部位）
Plueral friction rubs: N Y(position)胸膜摩擦音 无 有（部位）Heart 心
Inspection:bulging in precordial region : N Y apex impulse: 视诊 心前区隆起 无 有 心尖搏动
normal unseen increased diffusing position: normal 正常 未见 增强 弥散 心尖搏动位置 正常
deviation(the distance from midclavicular line cm)移动（距左锁骨中线内外 厘米）
Other precordial pulsations: N Y(position)其他部位搏动 无 有（部位）
Palpation:apex impulse:normal increased thrust unclear 触诊 心尖搏动 正常 增强 抬举感 触不清
thrills :N Y(position period)percardial friction rubs:N Y 震颤 无 有（部位 时期）心包摩擦感 无 有
Percussion:relative cardiac outline: normal shrink extant(right left)叩诊 相对浊音界 正常 缩小 扩大（右 左）
Ausculation: heart rate bpm/min rhythm(regular irregular 听诊 心率 次/分 心律（齐 不齐）
absolutly irrgelar)heart sound:S1 normal increased decreased 绝对不齐 心音 S1 正常 增强 减弱 split S2 normal increased decreased split 分裂 S2 正常 增强 减弱 分裂 S3 N Y S4 N Y A2 P2 S3 无 有 S4 无 有 A2 P2 Extra heart sound N gallop(diastolic presystotic summalion 额外心音 无 奔马律（舒张期 收缩前期 重叠
gallop)opening snap others murmurs: N Y(degree conduction)开瓣音 其他 杂音 无 有（图示并描述传导）Pericardial friction rubs N Y 心包摩擦音 无 有
Peripheral vessals: normal pistal shot of big arteries 周围血管 无异常血管征 大血管枪击音
Duroziez’s sign water hammer pulse capillary pulsation 二重杂音 水冲脉 毛细血管搏动
pulse deficit paradoxical pulse pulsus alternans other 脉搏短绌 奇脉 交替脉 其他 Abdoman 腹部
Inspection: shape normal distention frog abdomen(size cm)视诊 外形 正常 膨隆 蛙腹（腹围 厘米）
scaphoid apical abdomen gastral pattern intestinal pattern 舟腹 尖腹 胃型 肠型
peristalsis abdominal respiration:existance disappear umbilicus: 蠕动波 腹式呼吸 存在 消失 脐
normal protruding excretions others: N Y(venous distention of 正常凸出 分泌物 其他异常 无 有（腹壁静脉曲张 abdoman purple striae surgical scars hernia)条纹 手术疤痕 疝）
Palpation: soft muscle tension position tenderness N Y
触诊 柔软 腹肌紧张 部位 压痛 无 有rebound tenderness N Y fluidthtill N Y succussions plash N Y 反跳痛 无 有 液波震颤 无 有 振水音 无 有
Mass N Y(position size)discription of feature liver:can’t be 腹部包块 无 有（部位 大小）特征描述 肝 未触及
touched can be touched :subcostal cm under xipfoid process 可触及 肋下 厘米 剑突下
discription of feature gallbladder: can’t be touched can be touched 特征描述 胆囊 未触及 可触及 size cm tenderness N Y Murphy’s sign spleen: can’t be 大小 厘米 压痛 无 有 Murphy征 脾 未触及
touched can be touched distance from costal margin cm 可触及 肋下 厘米
Kideny:can’t be touched can be touched size consistency 肾 未触及 可触及 大小 硬度
tenderness mobility tenderness of ureters: N Y(position)压痛 移动度 输尿管压痛点 无 有（部位）
percussion: borders of liver dull(existance shrink obliteration)叩诊 肝浊音界（存在 缩小 消失）
Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线 肋间
shifting dullness N Y tenderness in renal region N Y(right left)移动性浊音 无 有 肾区叩痛 无 有（右 左）ausculation : borhorygmus normal increased decreased 听诊 肠鸣音 正常 增强 减弱
disappear gurgling N Y vessal bruits N Y(position)消失 气过水声 无 有 血管杂音 无 有（部位）
Genitalia :not examined normal abnormal Rectum and Anus : 生殖器 未查 正常 异常 肛门直肠 not examined normal abnormal 未查 正常 异常
Spine and Extremities 脊柱四肢
Spine : normal deformities(lateral anterior posterior protruding)脊柱 正常 畸形（侧 前 后凸）
Spinous process : tenderness pain while percussed(position)棘突 压痛 叩痛（部位）
Mobility : normal restricted extremeties: normal abnormal 移动度 正常 受限 四肢 正常 异常
deformity swelling of joints joints stiffness 畸形 关节红肿 关节强直
tenderness of muscles atrophy of muscles 肌肉压痛 肌肉萎缩
Venous distention of lower limbs(position and feature)acropachy 下肢静脉曲张（部位及特征）杵状指
Nervus System 神经系统
Abdominal wall reflex(normal)muscle tone(normal)腹壁反射（正常）肌张力（正常）
Myodynamia(degree)paralysis of limbs N Y(left right 肌力（级）肢体瘫痪 无 有（左 右
upper lower)biceps reflex left(normal)right(normal)上 下）肱二头肌反射 左（正常）右（正常）knee jerk left(normal)right(normal)achilles jerk left
膝健反射 左（正常）右（正常）跟腱反射 左(normal)right(normal)正常 右（正常）
Hoffmann’s dign left(+)(-)right(+)(-)Hoffmann征 左（+）(-)右（+）（-）Babinski’s sign left(+)（-）right(+)(-)Babinski 左（+）（-）右（+）（-）
Kernig’s sign left(+)（-）right(+)(-)others Kernig征 左（+）（-）右（+）（-）其他 Laboratory findings 实验室及器械检查结果（The important laboratory examination.X-ray.ECG and other result areincluded）(重要的化验、X线、心电图及其他有关化验)Nunber of X-ray X线片号 Abstract 病历摘要
Diagnosis(impressions)入院诊断
Recorder 病史记录者 Examiner 并使审阅者 Date of record 记录日期
第三篇：英文病例汇报实用句型
英文病例汇报实用句型
1.一般情况（完全套话）
Mr./Ms.**(family name), a **(age)year-old **(profession), was admitted on **(admission date).2.病史
He complains that...He complains of one-month history of palpitation and short of breathness after exertion.He complained about epigastric pain which has lasted for 3 months.He noticed a hardened lump on the left neck 3 months ago.Pancytopenia was found a month ago.He presented with dyspnea since 10 days ago.His chief complaint was...既往诊疗~~~~~~~~
He was confirmed as / definitely diagnosed as...(确诊为)
To make a definite diagnosis, bone marrow aspiration was performed.He was suspected as...(疑似)
The discomfort tended to worsening, which urged him to seek for medical care.He has been given 3 cycles of DA regimen for chemotherapy and complete remission was achieved only after the first cycle.He was given the thyroidectomy of the left lobe in local hospital.He was treated with antibiotics(details unknown), which didn't take effect as expected.The general condition is good at present.He was pain free now and hemodynamically stable.3.查体
Nothing noteworthy was found in the physical examination.There was nothing remarkable in the physical examination except for… The physical examination was otherwise normal except that…（上点小菜~~~血液科常见体征）
皮肤粘膜 generalized pallor，scattered petechiae，oral mucosal hematoma 淋巴结enlarged lymph nodes
头部yellow eyes(yellow-stained sclera)
胸部tenderness in sternum，coarse breath sound, cardiac murmur, arrhythmia
腹部enlargement of liver，splenomegaly
4．辅助检查
The laboratory findings suggested/indicated/demonstrated/showed that… Bone marrow film was performed, which confirmed the diagnosis of ALL.The results of blood routine showed that WBC count was 4,000 /cm3, while NEU count 2,500/cm3, hemoglobin 100 g/L, PLT count 100,000 /cm3.(/cm3 is pronounced as per cubic millimeter)
Chest CT scan supported the diagnosis of NHL.
第四篇：英文病例汇报常用体格检查术语
英文病例汇报常用体格检查术语
1、肋骨和软组织[ribs and soft tissure]
•胸骨上切迹[suprasternal notch]
•浮肋[free ribs]
•胸壁[chest wall]
•扁平（桶状、佝偻、漏头、鸡）胸[flat(barrel,rachitic, funnel, pigeon)chest] •皮下气肿[subcutaneous emphysema]
•捻发音[Crepitus]
•佝偻病串珠[rachitic rosary]
•软骨病[chondrosteoma]
•脂肪瘤[lipoma]
•软骨发育不全[achondroplasia(chondrodysplasia)]
•软组织损伤[soft tissue injury]
•肋骨畸形[abnormality of the ribs(rib deformity, costal anomaly)] •肋骨串珠（错位）[beading(displacement)of rib]
•肋软骨畸形[costochondral deformity]
•肋软骨增生[costal cartilage hyperplasia]
•肋下切口[subcostal incision]
•肋间隙宽（窄）[wide(narrow)intercostal space]
2、乳房[breast]
•对称性[symmetry]
•乳头内陷（内缩）[crater(retracted)nipple]
•乳头皱裂[cracked nipple]
•乳头偏斜（抬高）[nipple skewness(elevation)]
•乳头溢液[nipple discharge]
•乳头脓肿（溃疡、血肿）[abscess(ulcer, hematoma)of nipple]
•乳头过小[hypomastia]
•乳斑[milk spots]
•乳房潮红[breast flush]
•乳房出血[mastorrhagia]
•乳房过早发育[premature thelarche]
•乳房肿胀（脓肿）[mammary swelling(abscess)]
•乳房湿疹[eczema mammae]
•乳房下垂[mastoptosis(pendulous breast)]
•乳房萎缩[mastatrophy]
•巨乳[macromastia]
•乳晕[mammary areola]
•乳房硬化[zaranthan]医.学.全.在线.网.站.提供
•异常泌乳[abnormal lactation]
•男子女性化乳房[gynecomastism]
•乳房皮肤红肿[erythroswelling of mammary skin]
•乳房桔皮征[mammary orange-peel sign]
•乳记局限性凹陷[mammary localized pitting]
•乳房瘘管[breast fistula]
•正常女性乳房[normal female breasts]
•无压痛性肿块[nontender mass]
3、肺[lung]
•呼吸缓慢（急促）[bradypnea(tachypnea)]
•呼吸浅慢（深快）[hypopnea(hyperpnea)]
•呼吸不规则[irregular respiration]
•点头呼吸[nodding breathing]
•端坐呼吸[orthopnea]
•三凹征[retraction sign of three fossae]
•叹息样呼吸[sighing respiration]
•浅快[shallow and rapid]
•呼（吸）气性呼吸困难[expiratory(inspiratory)dyspnea]
•呼吸道烧伤（塌陷）[burn(collapse)of respiratory tract(airway)]
•呼吸道阻塞[respiratory tract obstruction]
•呼吸均匀（呼吸加深或加快）[eupnea(exaggerated or acclerated respiratory)]
•呼吸停止[apnea]
•呼吸费力[respiration is labored]
•语音（触觉）震颤[vocal(tactile)fremitus]
•语颤相等（减弱、增强）[vocal fremitus is equal(diminished, accentuated)]
•间接（直接）叩诊[mediate(immediate)percussion]
• 浊（实、鼓、清、过清、金属）音[dullness(flatness, tympany, vesicular resonance, hyperresonance, bell)]
•移动范围[range of movement]医学.全.在线.网.站.提供
• 呼吸音消失（减弱，增强）[absence(diminution, exaggeration)of breath sound] •呼吸音粗（清）[sound of breath(SOB)is rough(clear)]
•支气管（支气管肺泡，肺泡）音[bronchophony(bronchovesicular sound, vesicular sound)] •管状呼吸音[tubular breath sound]
•捻发音[crepitantrales]
•爆裂音[crackles]
•干（湿）罗音[dry(moist)rales]
•细（中等、粗）罗音[fine(medium, coarse)rales]
•呼（吸）气未罗音[end-inspiratory(expiratory)rales]
•胸膜摩擦音[pleural friction rub]
•呼（吸）气延长[prolonged inspiratory(expiratory)]
•高（低）调鼾音[sibilant(sonorous)rhonchi(sonorous rales)]
•哨笛音[sibilant rales]
•哮鸣音[wheezing]
•小（中、大）水泡音[small(middle, big)bubbles]
•支气管语音[bronchophony]
•耳语音[whispered]
•羊鸣音[egophony]
•高（低）音调[high(low)-pitched]
•两肺部（右背部）[over both lung fields(right back)]
•两（左）肺底[over the both(left)lower lung]
•整个肺野[the whole lung field]
•左（右）上（下）肺[the left(right)upper(lower)lung]
•肺尖（底）[apex(base)of lung]
4、心脏[Heart]
•用手掌（指尖）触诊心尖搏动[palpate apical area with palm(fingertips)]
•心前区隆起（凹陷）[precordial bulge(retraction)]
•搏动弥漫（局限）[diffuse(local)pulsation]
•负性搏动[inward inpulse]
•心尖搏动[apex beat(apical impulse)]
•剑突下搏动[xiphoideusalpulsaton]
•抬举性心尖搏动[heaving apex impulse]
•心尖搏动最强点[point of maximal impulse(PMI)]
•锁骨中线[mid-calvicular line(MCL)]
•肋间[intercostal space(ICS)]
•收缩（舒张）期震颤[systolic(diastolic)thrill]
•心浊音界[the border of cardiac dullnes]
•心绝对（相对）浊音界扩大（缩小）[enlarged(diminished)absolute(relative)cardiac dullness]
•叩诊心脏大小正常[heart size is normal on(to)percussion]
•心脏向左（右）扩大[cardiac dilation(enlargement)to the left(right)]
•第1（2、3、4）心音[S1(S2,S3,S4)]
•第1心音增强（减弱，听不清）[first heart sound is exaggerate(decreased, muffled)] •生（病）理性杂音（分裂）[physiologic(pathological)murmur(splitting)]
•生理性（固定、反常、逆）分裂[physiologic(fixed, paradoxical, reversed)splitting] •肺动脉瓣第2心音>(=，<)主动脉瓣第2心音[P2>(=，<)A2]
•大炮音[connon sound]
•心音消失[heart sound is absent(disapeared)]
•心音增强（减弱）[accentuated(diminished)cardiac sound]
•心音响亮（遥远）[cardiac sound is loud(distant)]
•收缩期（舒张期，连续性）杂音[systolic(diastolic, continuous)murmur]
•收缩（舒张）前（中、晚）期杂音[pre-(mid-, post)systolic(diastolic)murmur] •全收缩期的[holosystolic(pansystolic)]
•全舒张期的[holodiastolic(pandiastolic)]
•低（高）音调[low(high)pitched]
•递减（递增，递减-递增）性杂音[decrescendo(crescendo, decrescendo-crescendo)murmur] •呈喷射型[be ejection in type]
•Ⅳ级喷射型收缩期杂音[grade Ⅳ(I-Ⅳ/6)systolic ejection murmur]
•吹风样杂音[murmur of puffing character]
•低音调隆隆样[low-pitched rumbling quality]
•柔和（粗糙）的[soft(harsh or rough)]
•吹风样（喷射性、隆隆样、沙沙声样、搔抓声样、机器声样、汽笛声样、倒水声样）杂音[blowing(ejection, rumbling, rustting, scratching, machinary, whistling, pouring)murmur]
•功能性（器质性）杂音[functional(organic)murmur]
•血管（静脉）杂音[vascular(venous)murmur]
•枪击音[pistol shot sound]医学全.在线网.站.提供
•静脉营营音[venous hum]
•奔马律[gallop rhythm]
•胎心律[embryocardia]
•心律齐（不齐）[regular(irregular)rhythm]
•心律不齐[arrhythmia]
•二
（三）联律[bigeminy(trigeminy)]
•早搏[premature(extrasystol)]
•喀嗽音[click]
•钟摆律[pendular rhythm]
•二尖瓣开瓣音[mitral opening snap]
•心包摩擦音[pericardial friction sound]
•听诊[on auscultation]
•二尖瓣（主瓣，肺瓣，三尖瓣）听诊区[mitral(aortic, pulmonary, tricuspid)valve area] •心包叩击音[pericardial knock]
•肿瘤扑落音[tumor plop]
5、腹部[abdomen]
•腹（妊娠）纹[abdominal striae(striaegravidarum)]
•腹膨隆[abdominal distention(prominence)]
•腹平坦（凹陷）[abdominal flatness(retraction)]
•蛙状（球状、舟状）腹[frog(bulbous, scaphoid)belly(abdomen)]
•腹围增大[increased abdominal girth]
•肠型[intestinal pattern]
•梯形腹[ladder-shaped abdomen]
•胃（小肠）蠕动波[gastric(intestinal)peristaltic wave]
•静脉曲张[varicosity(dilated tortuous vein)]
•疤痕[scar]
•腹壁紧张（松驰）[guarding(abdominal muscular relaxation)]
•腹壁切口（创伤）[incision(wound)of abdominal wall]
•腹部分区[abdominal region]
•左（右）上（下）腹[left(right)upper(lower)quadrant]
•脐膨出[projection of the umbilicus]
•腹式呼吸[abdominal(diaphragmatic)breathing]
•腹壁松弛[lax abdominal wall]
•肝肿大[hepatomegaly(enlargement of the liver)]
•脾肿大[splenomegaly(enlargement of the spleen)]
•右肋下5厘米[5 cm below the right costal margin]
•肿块（肝）质硬[firm mass(liver)]
•莫菲氏征[murphy`s sigh]
•肌卫现象[muscle guarding(tension)]
•反跳痛[rebound tenderness]
•压痛点[tenderness point]
•剑突下压痛[tenderness beneath the xiphoid process]
•麦氏点压痛[McBurney`s point tenderness]
•腹肌强直（板状腹，板样强直）[rigor of abdominal muscle(wooden belly, board-like rigidity)]
•柔韧感[dough kneeding sensation]医学.全在线
•波动感[fluctuation]
•腹股沟疝[inguinofemoral hernia]
•腹壁反射[abdominal reflex]
•腹水征[sign of ascites]
•膀胱肿大[bladder expansion]
•膀胱区（脊肋角）压痛[tenderness of bladder region(costovertebral angle)]
•肾（肝）区叩击病[percussion tenderness on kidney(liver)region]
•移动性浊音[shifting dullness]
•鼓音[tympany(tampanitic resonance)]
•肝（脾）浊音区[hepatic(splenic)dullness area]
•肠鸣音正常（亢进、减弱、消失）[normal(hyperactive, diminished, absent)bowel sound] •气过水声[gurgling]
•振水声[succusion(splashing)sound]
第五篇：病例演讲比赛
3c群英汇病例演讲比赛评分表 注：第一部分临床病例分享考核项目为每栏20分计，第二部分演讲部分为每栏10分计，总分每位选手100分。篇二：医院演讲比赛演讲稿
怀抱使命奉献青春
尊敬的各位领导、各位同仁，大家好：
“致力于持续发掘资源价值，追求人与自然的和谐共生”是企业人的使命，也是全面落实科学发展观的要求。正因为我们企业的发展理念符合现代企业发展的要求，才得以跻身世界五百强企业，并打造出世界一流的标杆工厂。作为一名职工医院的医护人员，我们的使命和职责就是救死扶伤，急病人之所急，想病人之所想，确保每一个病人都能得到及时、准确的救治，减少病人的痛苦。王国维先生曾说:“生命在于追求，人生在于奉献”。我想，这字里行间中孕育的深刻内涵，就是我们年轻人”如何谱写青春旋律的最佳答案，那就是爱岗敬业，无私奉献。在我们的身边就有这样一群人，他们就是我最亲密的战友和伙伴，一群兢兢业业、勤勤恳恳、任劳任怨、无怨无悔、爱岗敬业、甘于奉献的白衣天使。xxx是我们医院内儿科主任，从医近30年，他一直把患者的利益放在第一位，从不计较个人得失，不论白天黑夜，值班还是休息，只要科室有事，他总是能第一时间赶到。作为科室带头人，他有着高度的责任心和极强的综合分析能力。遇上内科急诊，他每次都用百分之百的全力以赴争取患者一秒的抢救时机，有条不紊地指导、参加现场急救。一天下午，一位急诊患者大汗淋漓，全身抽搐，突然意识丧失，根据经验，x主任立刻对其进行心电图检查，是心室颤动！病情
危急，死亡率极高，转院又来不及，整个抢救室迅速凝集了一股紧张的气氛，绝不能错过这几分钟的黄金抢救机会，于是x主任与院领导立刻组织电除颤抢救，除颤一次、两次„，奇迹发生了，患者心电监护显示各指标逐渐正常。这时x主任赶紧联系患者转院事宜，由于抢救及时，患者在上级医院成功进行了手术治疗，后来患者从上级医院出院后回来说：我这个病能在你们医院抢救成功，就连上级医院都觉得很了不起呢!在x主任的指导下，内儿科成功抢救过脑梗死、心肌梗死，肝性脑病、肺性脑病、高血压危象，急性一氧化碳中毒、急性有机磷中毒等急诊病例。这些危重患者的抢救成功，无不印证着xxx同志高尚的医德和精湛的医术！
从他身上我懂得了，作为医务工作者，我们要有强烈的主人翁意识，我们要像爱家一样，爱上自己的工作，爱上自己所从事的岗位。只有对一草一木有真感情，对工作才有兴趣，产生了兴趣才可能把工作做的更好，才能在岗位上甘于奉献。从他身上我懂得了，我们每个人不一定都能做出轰轰烈烈的事，每个工作岗位也不一定都能显出伟大高尚，但只要坚定信念尽心尽责，就能实现不一定高尚但绝对不会渺小的完美人生价值。
怀抱使命，是我们追求卓越的动力，甘于奉献是我们前进动力的保障。世界因使命不断前进；世界因奉献而精彩，社会因奉献而和谐，企业因奉献而强大。大地的绿荫是森林对地球的奉献，万物的生机是阳光对生命的奉献，病人的笑容是我们医务工作者者对病人的奉
献，这就是我们医务工作者怀着满腔热忱，用真诚和执著奉献青春、点亮人生的最好诠释。篇三：病例演讲技巧观察评估表
病例演讲技巧观察评估表 篇四：演讲比赛主持词
“激扬青春，和谐校园”演讲比赛主持词
四月，我们呼吸着春天的气息，沐浴着阳光的温暖。我们播种着人生的希望，催生着理想的绽放。我们享受着和平的宁静，缅怀着逝去的英灵„„.尊敬的各位领导、各位评委、亲爱的同学们：大家下午好！
在这春和景明，芳菲满园的季节，在这“五一”国际劳动节和“五四”青年节来临之际，在学校各级领导的大力支持下，我们迎来了主题为“激扬青春，和谐校园”的大型演讲比赛，共叙对和谐校园的讴歌之情，共抒对祖国的热爱之情，共谱青春激扬的美妙乐章。
首先，请允许我来介绍出席本次演讲比赛的领导，他们是： 让我们用热烈的掌声欢迎他们到来，感谢你们在百忙之中来到比赛现场。
接下来，请允许我介绍此次演讲比赛的评委，他们是： 让我们同样以热烈的掌声欢迎他们。
下面，我为大家宣读此次演讲比赛的评分标准及奖项设置。（宣读比赛的要求及评分规则）
此次演讲分演讲内容、语言表达、形象风度、综合印象四部分对演讲选手进行评分。满分为10分。决赛实行现场亮分制，评委打分后去掉一个最高分和一个最低分，汇总后取平均分，精确到小数点后两位，为选手最后得分。其中
1、演讲内容占4分。要求演讲内容紧扣主题，主题鲜明、语言自然流畅，富有真情实感。
2、语言表达占3分。声音洪亮，口齿清晰，普通话标准，表达流畅，动作恰当。
3、形象风度占2分。要求衣着整洁，仪态端庄大方，上下场致意，答谢等。
4、综合印象占1分。由评委根据演讲选手的临场表现作出综合演讲素质的评价。本次比赛奖项设置为一等奖1名，二等奖2名，三等奖3名，优秀奖7名。以上均为此次比赛的评分标准和奖项设置。
现在我宣布“激扬青春，和谐校园”演讲比赛决赛现在开始。
首先让我们用热烈的掌声有请出进入决赛的 名选手登场亮相。有请他们闪亮登场 我们 名参赛选手已全部站在舞台中央了，让我们一起来认识一下他们，首先1号参赛选手是来自 的，2号参赛选手是来自 3号参赛选手是来自 4号参赛选手是来自 5号参赛选手是来自 6号参赛选手是来自 7号参赛选手是来自 8号参赛选手是来自 9号参赛选手是来自 10号参赛选手是来自 11号参赛选手是来自 12号参赛选手是来自
我们本场比赛的最后一位参赛选手是来自。亲爱的朋友们让我们再一次把掌声送给即将上场的 位参赛选手。他们在本场演讲比赛中，将满怀最真挚的情感，用最优美的语言，表达他们对和谐校园以
及青春的美好祝福，同时也希望各参赛选手能够在比赛中发挥出最好水平，展现出最佳风采！
二、感谢1号选手的精彩演讲，请各位评委为1号参赛选手亮分
我们是火焰，我们是太阳„„释放光芒是我们神圣的职责，奉献温暖是我们无尽的追求。勤劳的乌兰人一直在为乌兰的做大、做强、做久，为伟大的社会主义事业奉献自己的光和热！接下来请听来自科胜人造板厂的2号参赛选手张伦为我们带来的演讲《开拓奋进，再创辉煌》。
三、下面为大家公布1号选手的最后得分，1号选手李媛的最后得分为 祝贺她。
接下来请各位评委为2号参赛选手亮分
三个月的工作，他告别了学生时代的懵懂和无知，懂得了社会处处可以为师表，启迪着他谦虚做人；他放下了学生时代的心比天高，明白了人生大道需一步一个脚印，激励他踏踏实实的做事。这是乌兰新员工发自内心的感受。接下来请听来自经销公司的3号选手邱亮的演讲《忠爱祖国，奉献乌兰》。
四、下面为大家公布2号选手的最后得分，2号选手张伦的最后得分为 祝贺他。
接下来请各位评委为3号参赛选手亮分
因为身为龙的传人与生俱来的情感。作为一名乌兰员工，爱国首先就要做到热爱自己的企业。下面有请来自泰威化工厂的4号选手赵鑫带来他的演讲《爱我中华谋发展，我与乌兰共成长》。
五、下面为大家公布3号选手的最后得分，3号选手邱亮的最后得分为 祝贺他。
接下来请各位评委为4号参赛选手亮分
感恩这个特别温馨的词，暖暖地写在我们每个人心中。感恩是一种信念，感恩是一种态度，感恩是一种情怀，感恩更是一种向上的力量！接下来请听来自泰安建材公司的5号参赛选手李玮华的演讲《感恩乌兰，感恩铸就忠诚》
六、下面为大家公布4号选手的最后得分4号选手赵鑫的最后得分为 祝贺他。接下来请各位评委为5号参赛选手亮分
雷锋曾在日记中这样写过“如果你是一滴水、你是否滋润了一寸土地；如果你是一线阳光，你是否照亮一分黑暗；如果你是一颗螺丝钉、你是否永远坚守你的岗位。”这是一种爱岗敬业的精神，一种无私奉献的精神。掌声有请来自瑞丰热电公司的6号参赛选手薛东锦带来他的演讲《爱我中华，我爱乌兰》。
七、下面为大家公布5号参赛选手的最后，5号选手李玮华的最后得分为 祝贺他。
接下来请各位评委为6号参赛选手亮分
感恩是一种情怀，敬业是以一个员工最基本的品质，爱国是每一个中国都应铭记的使命。下面有请来自满来壕煤矿的 7号选手王艳丽为大家带来她的演讲《爱我 乌兰之感恩、敬业、爱国》。
八、下面为大家公布6号参赛选手的最后，6号选手薛东锦的最后得分为 祝贺他。
接下来请各位评委为7号参赛选手亮分
接下来有请来自温三号煤矿的8号参赛选手尹鹭为我们带来他的演讲《热爱乌兰、奉献乌兰》
九、下面为大家公布7号参赛选手的最后得分，7号选手王艳丽的最后得分为 祝贺他。
接下来请各位评委为8号参赛选手亮分
作为乌兰集团的新生力量，广大青年职工肩负着继承和开拓的历史任务，他们用青春的色彩在集团公司的宏伟蓝图上尽情挥洒，奏响了一曲曲动人的新时代青春之歌。请听来自大自然公司的9号选手张宇琳的演讲《激扬青春，奉献乌兰》。
十、下面为大家公布8号参赛选手的最后得分，8号选手尹鹭的最后得分为 祝贺他。
接下来请各位评委为9号参赛选手亮分
接下来有请来自阿四收费站的10号才赛选手王雪梅的演讲《乌兰人、乌兰请》
十一、下面为大家公布9号参赛选手的最后得分，9号选手张宇琳的最后得分为 祝贺他。
接下来请各位评委为10号参赛选手亮分
半个多世纪前，著名诗人艾青曾在《我爱这土地》这首诗里深情的说：“为什么篇五：演讲比赛流程(呈现在邀请函上)9:00-9:15 入场拉票，决定演讲顺序
演讲专家每人有1分钟拉票时间，听众进行投票选择自己支持的演讲专家，根据投票结果，票数最高的专家首先选择演讲顺序，依次类推，确定五位演讲专家的演讲次序。9:45-11:25 演讲比赛 演讲—评委评分—后援团拉票—大众投票 ? ? ? ? ? ? ? 演讲专家按照次序依次演讲，每人15分钟； 专家演讲结束后，五位评委进行评分，并做简要点评，最高分20分，五位评委分数之和则为该专家在此环节得分； 评委点评后，后援团可推举一人面向听众阐述病例要点并拉票，每人3分钟； 听众利用投票器为支持的专家投票，投票赞成者票数之和为该专家在此环节得分。专家演讲得分为评委评分和大众投票之和，依次决出名次； 分数相同者，大会主席决定名次先后； 按照排名顺序依次挑选奖品，即冠军首先挑选奖品，依次类推。
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