大病例中英文對(duì)照(文件)
【正文】 NegativeHistory of longterm drug use: NegativeHistory of drug abuse: Negative系統(tǒng)回顧(Review of Systems)： GI: No hematemesis, swallowing difficulty, abdominal pain or distention, diarrhea, occult blood, constipation, jaundice, rash or itching. Musculoskeletal: No dysarthria, joint abnormality, spine abnormality, muscle atrophy or weakness in limbs.C Weight: not measured kg Height: not measured cm Posture: Can answer correctly and collaborates. 皮膚、黏膜(Skin、Mucosa)：Color: Refer to speciality Rash: Absent Hemorrhage: Absent Edema: refer to specialitySuperficial lymph nodes: No enlargement of superficial lymph nodes in the whole body頭部及其器官(Head and HEENT)：Shape of head: Normal Conjunctiva: No hyperemia or edema Sclera: Refer to speciality Pupil: Symmetrically round Nasal cavity: Clear Sinus tenderness: Absent Teeth: Normal Oral mucosa: Normal Mastoid tenderness: Absent Hearing: No abnormality Tonsils: No enlargement Others: Negative頸部（Neck）:Flex: Soft position of trachea: Midline thyroid gland: No enlargement Jugular vein: No distension Others: None 胸部(Chest)：Shape: Normal, symmetric intercostals space: Normal Breasts: Symmetric, no abnormality 肺臟(Lungs)：Breathing: Symmetric percussion sound: Clear breath sounds: Clear Crackles: Absent Others: Absent 心臟(Heart)：Heart rate: 78 bpm Heart sounds: Normal Murmurs: Absent Others: Absent 血管(Blood Vessel)：Peripheral vessel sign: Negative腹部(Abdomen)： Refer to speciality 外生殖器(Genitourinary system)：not examined直腸、肛門(Rectum、Anus)： Not examined四肢、脊柱(Extremities、Spine)：No abnormality 神經(jīng)系統(tǒng)(Neural System
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鄂ICP備17016276號(hào)-1