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1、呼吸科常用英文询问病史 case historyYou need to get a detailed history including the timing and acuity of onset, exacerbating and alleviating factors and environment triggers to help you confirm a diagnosis or discard other diseases /develop a differential diagnosis. Ask your patient whether there is a history
2、of tobacco use, or other toxic and environmental exposures and his occupational history.General/biographical data,marital status, nativity, occupation, informant, time of admission and record, chief plaint, history of present illness, previous health status, any infectious diseases, allergic history
3、, history of trauma or surgery, smoking , alcohol intake,spouses health status, menorrhea , childbearing or pregnancy times , natural labor, abortions ,premature delivery, stillbirths, difficult labor, family history 常用的症状 symptomsfeverCough 咳嗽Sputum 10 mmHg Oon inspiration vseen in severe asthmabar
4、rel chest hyperexpanded, decreased expansion kyphosis 驼背,脊柱后凸Inspection:tachypnea 呼吸急促accessory muscles of respiration: sternocleidomastoid muscle, arm support, alae flaringwide or narrow intercostal space tactile vocal fremitus 触觉语颤 subcutaneous crepitus 皮下捻发感 Percussion: resonance dullness flatnes
5、s hyperresonance tympanylower borders: scapular line X left/right intercostal space range of mobilityAuscultation:vocal resonance 语音共振ronchi: wheeze , stridor , crackles, Velcro-like soundes moist rales : coarse, medium, fine, crepitus 捻发音 pleural friction rubs plete absence of breath sounds ankle e
6、demaweight loss,cachexia 恶病质cachectic 恶病质的 decreased food appetite, loss of appetite, anorexia 食欲减退 常做的检查 examinations or laboratory findings temperature charts 体温图 sputum pot 痰盂Blood/urine/stool routine, occult blood testBlood biochemistrySputum /blood culture and drug sensitivity test sputum cytol
7、ogyPulse oximeter 脉氧计：continuous monitoring of blood oxygen saturationArterial blood gas analysis: arterial blood sampling , radial/ femoral artery puncturePaCO2: partial pressure of carbon dioxide in arterial blood hypercarbiaPaO2: partial pressure of oxygen in arterial blood hypoxemia respiratory
8、failure:type 1: decreased 02 supply, PaO2V 60 mmHgvmillimeters of mercurydue to diffusion failure or V/Q dismatch ventilation-perfusionratiopulmonary edema, pneumonia, infarction, fibrosis,or pulmonary embolism,pulmonary hypertension, shunttype 2: decreased CO2 removal, PaCO25O mmHgvmillimeters of m
9、ercurydue to alveolar ventilation failureobstructive: COPD, asthma, bronchiectasisrestrictive: neuromuscular , structural , pleural diseases ,obesityChest X-ray/radiograph:reticulo-nodular shadowing coin lesions 硬币样cavities 空腔：amphoric 空翁音的vbreathing like blowing over a bottle topopacification 浑浊： consolidation : confluent shadowing and air bronchogram collapse: lobar segmental atelactasis pleural effusionmediastinal mass: thyroid ,thymoma, teratoma, TB lymph nodes, terrible diagnoses including lymphoma and aneurysm Chest CT scan Head MRIPET-CT of the whole body Abdominal ultrasoundskin pric
