病历书写英文单词.docx
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病历书写英文单词.docx
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病历书写英文单词
现病史[Historyofpresentillness(HPI/PI)]
现病史书写的重点包括:
一、主诉中症状的详细描述;
二、疾病的发展过程;
三、诊疗经过;
四、目前的一般情况。
1、诱因
·无诱因下[Withnoinducingfactors]
·无明显诱因下[Undernoobviouspredisposingcauses]
·感冒一周后[Aftergetting(catching)commoncoldfor1week]
2、症状出现的叙述
·有……症状
▲sufferfrom
▲haveanattackof
▲have(fell)
▲begintofell
▲afeeling(sensation)of……
▲complain(of)
▲……sensation(feeling)in(of)……
▲[发热]haveatemperature(becomefeverish)
·在……情况下发生
▲活动时呼吸困难[dyspneaonexertion]
▲躺下后即出现咳嗽[Coughoccurssoonafterlying]
·与……有(无)关
▲与……有关[beassociatedwith]
▲与……有关[have(make)relationto]
▲与……无关[have(make)norelationto]
·在……情况下加重(减轻)
▲餐后加重[becomeworseaftertakingmeals]
▲站立后缓解[berelievedbystandingup]
▲随呼吸和咳嗽而加重[becomemoreseverewithbreathingandcough]
·伴有……
▲beaccompaniedby
3、起病方式
·急性腹痛[acuteabdominalpain]
·慢性低热[chroniclowerfever]
·暴发性发病[theonsetwasfulminating]
·骤起胸痛[anexplosiveonsetofchestpain]
·突然起病伴高热[theonsetwassuddenwithhighfever]
·突发突止[attacksbeganandendedabruptly]
·因……而突然起病[theattackisprecipitatedby……]
·很快发生晕厥[syncopeoccuredrapidly]
·逐渐出现咳嗽咳痰[gradualonsetofcoughandsputum]
·偶而[occasionally(sporadically,accidentally)]
·反复胸闷心悸[recurrent(boutsof)chestdiscomfortandpalpitation]
·一过性发作[transitoryattack]
·连续胸痛[chestpaincontinually]
·时重时轻[wanedandwaxed]
·时好时坏[hanginthebalance]
·不停地咳嗽[haveafitofcough]
·发作性呼吸困难[paroxysmalshortofbreath]
·频繁咳嗽[coughfrequently(veryoften)]
·持续性(间歇性)[persistent(intermittent)]
·频发胸痛[frequentepisodesofchestpain]
·持续不变[besteady]
4、病情变化描述
·[症状好转]▲fellbetterthanbefore
▲takeafavorableturn
▲takeaturnforthebetter
▲improve
▲makefavorableprogress
▲turnforthebetter
▲changeforthebetter
▲bebetter
·[症状减轻]▲alleviate
▲reduce
▲palliate
▲diminish
▲ease(lighten)
▲mitigate
·[症状消失]▲disappear
▲subside
▲regress
▲clearup
▲vanish
▲dissolve
▲die(fade)away
▲relieve
·[症状加重]▲be(make,become,get)worse
▲worsen
▲becomemoresevere
▲takeaturnfortheworse
▲beaggravated
▲increaseinseverity
▲takeabadturn
▲make(become)moreserious
▲make(become)heavier
·[无变化]▲remainthesameas……
▲continuewithoutchange
▲beidentical
▲bealike
▲besimilar
▲resemble
·[时好时坏]▲waneandwax
▲hanginthebalance
·[体温/血压升降]
▲升至[rise(goup)to]
▲已升至[haverisen(goneup)to]
▲从……升至……[goupfrom……to……]
▲升至[beelevatedto]
▲迅速下降[fall(decline,abate)abruptly]
▲骤降(升)[suddendrop(elevation)]
▲渐降(升)[fall(elevate)gradually]
▲缓慢下降[slowcrisis(lysis)of]
▲一天天下降[be(become)lowerdaybyday]
▲开始降低[begintoremit]
▲降至正常[drop(wasreduced)tonormal]
▲已降至[havegonedown(dropped)to]
▲回复到正常[return(revert)tonormal]
▲由……降(升)至……[fall(elevate)from……to……]
▲维持在……水平[maintainatalevelof……]
▲稳定在……[stabilizeat……]
▲热退了[feverdisappeared]
▲不超过[donotgoupover(exceed)……]
▲在……和……之间波动[fluctuate(vary)between……
and……]
▲在……至……范围内[rangefrom……to……]
▲平均38.5℃[anaveragetemperatureof38.5℃]
▲有39.2℃的体温[havefever(atemperature)of39.2℃]
5、症状的时间表示
·持续▲lastedfor2days
▲havegoneonfor1month
▲havecontinuedfor10hours
▲lastedontheaverage3-5hours
▲lastedavariabletimefrom5minutestoseveralhours
▲lastedabouthalfanhour
·超过(不到)[movethan(lessthan)]
·……以前[twoyearsago]
·多在……时发生[usuallybetween3and5PM]
·未发作过[befreeofonsets(attacks)for2weeks]
6、症状的严重程度
·轻度[mild(slight)]
·中度[moderate]
·重度[severe(serious)]
7、症状的其他描述方法
·[部位]▲belocated(situated)in(over)[位于]
▲Thereislocalizedpainin……[疼痛位于]
▲near……[在……附近]
▲belocalizedto(in,over)[局限于]
▲belimited(confined)to[局限于]
·[表示部位的介词]
▲心尖部,表示小的部位或点[attheapex]
▲上腹部,表示大的部位[intheupperabdomen]
▲在左下肢,表示皮肤表面上(下)的病变[on(beneath)the
leftlowerlimb]
▲在右肺,表示正上方的相应体表部位[overtherightlung]
▲嘴上(下)方,表示高低或上下的位置关系[above(below)
themouth]
▲左乳皮下[undertheskinoftheleftbreast]
·[转移/放射]
▲转移到……[shift(migrate)to……]
▲放射到……[radiate(travel,go,refer)to……]
▲从……放射到……[radiatefrom……to……]
·[耳鼻咽喉及口腔症状]
▲耳痛[otalgia(painofears)]
▲耳鸣[tinnitus(earsring)]
▲耳鸣[abuzzing(ringing,singing)intheears]
▲左耳有耳鸣感[abuzzingsensationintheleftear]
▲耳聋[deafness(lossinhearing)]
▲左耳聋[bedeafoftheleftear]
▲耳流脓[otorrhea(otopyorrhea)]
▲耳出血[otorrhagia]
▲耳垢[cerumen(earwax)]
▲耳血肿[othematoma]
▲鼻塞[nasalobstruction]
▲不能用鼻呼吸[beunabletobreathethrough(by)thenose
(nasaldyspnea)]
▲打喷涕和流涕[sneezingandnasaldischarge]
▲水样鼻涕[wateryrhinorrhea]
▲鼻出血[nosebleed]
▲咽喉痛[sorethroat]
▲口吃[stuttering]
▲口臭[ozostomia(saburra,halitosis)]
▲张口困难[difficult(inability)toopenthemouth]
▲张口(吞咽、嚼)困难[difficultinopeningthemouth
(swallowing,masticating)]
▲咽下困难[dysphagia]
▲流涎多[haveexcessivesalvation]
·[眼科及牙科症状]
▲眼睑浮肿[eyelidedema]
▲眼痛[painintheeyes]
▲视边模糊[blurringofvision(blurredvision)]
▲过度流泪[excessivetearing(watering)]
▲视疲劳[asthenopia(visionaltired)]
▲视力减退[hypopsia(diminutionofvision)]
▲视力衰弱[ophthalmocopia]
▲远(近)视力模糊[indistinctdistant(near)vision]
▲失明[lossofvision]
▲搏动性牙痛[throbbingpainoftooth(odontalgia)]
▲牙龈出血[gingivalbleeding]
▲牙龈萎缩(增生)[gingivalatrophy(hypertrophy)]
▲牙周溢脓[peripyema]
·[妇产科症状]
▲月经过多[excessivemenstrualflow(menorrhagia)]
▲月经多并伴血块[experiencemenorrhagiawithpassageof
clots]
▲经量少(中等、多)[mild(moderate,heavy)menses]
▲月经过少[hypomenorrhea]
▲阴道出血[vaginalbleeding(colporrhagia)]
▲阴道大出血[massive(profuse)vaginalbleeding]
▲无痛性(性交后)阴道出血[painless(postcoital)vaginal
bleeding]
▲阴道干燥[colpoxerosis]
▲月经规则(不规则)[rugular(irregular)menstrualcycle]
▲月经周期26天,持续4天[menstrualperiodsof26daysand
lasted4days]
▲白带增多[leukorrhagia(profuseleukorrheaorwhites)]
▲外阴搔痒[pruritusofvulva]
▲外阴湿疹(白斑)[eczema(leukoplakia)ofvulva]
▲绝经[amenorrhea]
▲停经[menopause]
▲停经3年[3yearspostmenopausal]
▲50岁停经[Passedmenopauseatage50]
▲经前(期)痛[painbefore(during)theflow]
▲预产期[expecteddateofconfinement]
▲见红和破水[showandamnioticfluidescaped(ruptureof
membranes)]
▲羊水过多(少)[polyhydramnios(oligohydramnios)]
▲月经期水肿[menstrualedema]
▲月经失调[menstrualdisorder]
▲性欲正常(减退)[normal(decreased)libido]
▲无性欲[lossoflibido]
▲性功能障碍[sexualdisorder]
▲性变态[paraphilia]
▲性要求高(低)[beoversexed(undersexed)]
▲性感不快[dypareunia]
▲性欲亢进(减退)[hypersexuality(hyposexuality)]
▲产程[stageoflabor]
▲产程延长[prolongedlabor]
▲产道裂伤(损伤)[laceration(injury)ofbirthcanal]
▲产后腹痛(出血,尿潴留,子痫)[postpartumtormina
(hemorrhage,retentionofurine,eclampsia)]
▲产前出血[antepartumhemorrhage]
▲产前子痫[prenataleclampsia]
▲产前检查[prenatalexamination]
▲产褥热[puerperalfever]
▲产褥期护理[pureperalcare]
▲妊娠呕吐[vomitingofpregnancy(hyperemesisgravidarum)]
▲妊娠反应[pregnancyreaction]
▲妊娠高血压(水肿)[gestationhypertension(edema)]
·[病程中的一般情况]
▲一般情况尚可(一般、差)[generalconditionisfair(ordinary,bad)]
▲胃纳佳(差)[haveagood(poor)appetite]
▲过度进食[eattoomuch(overeat,eatheavily)]
▲过少进食[eatpoorly(takelittlefood)]
▲无食欲[havenoappetite]
▲食欲减退[appetitedecreases]
▲口渴[feelthirsty]
▲大量饮水[drinkwatergenerously]
▲体重增加[gaininweight]
▲体重增加8公斤[a8kilogramsweightgain(gain8kilograms)]
▲体重减轻[lossofweight(weightloss)]
▲体重稳定不变[bodyweightisstable(unchanged,maintained)]
▲睡眠障碍[somnipathy]
▲睡眠不足[lack(want)ofsleep]
▲不易入睡[havetroublegettingtosleep]
▲容易入睡[fallintoasleepveryeasily]
▲睡眠过度[hypersomnia]
▲睡行症[sleepwalking]
▲嗜(贪)睡[somnolence(befondofsleep)]
▲夜晚因……而易醒[easilywakenedatnightbecauseof……]
▲失眠[haveinsomnia]
▲睡眠差(好)[sleepispoor(good)]
▲消化不良[dyspepsia(havebaddigestion)]
▲大(小)便通畅[stool(urination)iseasyandsmooth(unobstructed,clear)]
▲每日2次大便[havetwostoolsdaily]
▲含粘液的水样便[waterystoolscoutainingmucus]
▲便秘(腹泻)[constipation(diarrhea)]
▲排尿困难[difficultyinmicturition]
▲尿频(急)[frequency(urgency)ofmicturition]
▲尿痛[micturitionpain]
▲少尿(无尿、多尿)[oliguria(anuria,polyuria)]
▲大便失禁[fecalincontinence]
▲小便失禁[incontinenceofurine]
▲精神不振[lassitude]
▲精神紧张(抑郁)[mentalstress(depression)]
▲精神混乱[confusion]
▲精神失常[amentia(mentalstateisbad)]
▲精神状态正常[orthophrenia(mentalstateisgood)]
▲体力旺盛(不足,正常)[hypersthenia(hyposthenia,euthesia)]
[Name]姓名
·[Sex]性别
·[Age]年龄
·[Occupation]职业
·[Dateofbirth]出生日期
·[Marriage(Maritalstatus)]婚姻
·[Race]民族
·[Placeofbirth(Birthplace)]籍贯
·[IdentificationNo.(codeofIDcardNo.)]身份证号码
·[DepartmentofworkandTEL.No.(UnitandBusinessphoneNo.)]工作单位及电话
·[HomeaddressandphoneNo.]家庭住址及电话
·[Postcode]邮政编码
·[Persontonotify(Correspondent)andphoneNo.]联系人及电话
·[Source(Complainer;offerer;supplier;provider)ofhistory]病史陈术者
·[Reliabilityofhistory]病史可靠程试
·[Medicalsecurity(Typeofpayment)]医疗费用
·[Typeofadmission(Patientcondition)]住院类别(入院时病情)
·[MedicalrecordNo.]病历号
·[Clinicdiagnosis]门诊诊断
·[Dateofadmission(admissiondate)]入院日期
·[Dateofrecord]记录日期
1、年龄的表示方法(以36岁为例)
·36yearsold(y/o)
·Age36
·36year-old
·Theageof36
·36yearsofage
2、性别的表示方法
·[Male,♂]男性
·[Female,♀]女性
3、职业的表示方法
·工人[Worker]
·退休工作[Retiredworker]
·农民[Farmer(peasant)]
·干部[Leader(cadre)]
·行政人员[administrativepersonnel(staff)]
·职员[staffmember]
·商人[Trader(Businessman)]
·教师[Teacher]
·学生[Student]
·医生[Doctor]
·药剂师[Pharmacist]
·护士[Nurse]
·军人[Soldier]
·警察[Policeman]
·工程师[Engineer]
·技术员[Technician]
·家政人员[Housekeeper]
·家庭主妇[Housewife]
·营业员[Assistant]
·服务员[Attendant]
·售票员[Conductor]
4、民族的表示方法
·汉[Han]
·回[Hui]
·蒙[Meng]
·藏[Tibetan]
·朝鲜[Korean]
·美国人[American]
·日本人[Japanese]
·英国人[Britisher]
5、医疗费用的表示方法
·[Selfpay(Individualmedicalcare)]自费
·[Governmentinsruance(Publicmedicalcare)]公费
·[Insurance]保险
·[Localinsurance]本地医保
·[Non-localinsurance]外地医保
·[Laborprotestioncare]劳保
6、婚姻状况的表示方法
·[Married]已婚
·[Single(Unmarried)]未婚
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