医学英文

病例介绍病例书写内容1.基本信息General data：name，sex，age，native，birth place，profession, marital status, source of history and estimate of reliability，etc.基本信息：姓名，性别，年龄，籍贯，出生地，职业，婚姻状况，历史来源和可靠度等。

2.主诉Chief complaints: It should constitute in a few simple words describing the main reasons why the patient consulted his physician, which usually includes symptoms or sign the patient is s uffering.主诉：用一些简单的词汇来描述患者就诊的主要原因，通常包括患者的症状或体征。

3.现病史Present illness:It should be a well-organized，sequentially developed elaboration of patients chief complaint or complaints. A good medical historywill reflect the diagnosis or impression which is going to be made.现病史：对病人的主诉进行条理清楚、有次序的详细阐述。

好的病史可以反映出将要做出的诊断或印象。

It includes the following aspects:1.Onset and duration of the disease. 疾病的发病和持续时间。

2. Main symptoms, location and their character3.Etiology [ˌi:tɪ'ɒlədʒɪ] and provoking [prə'vəʊkɪŋ] factors. 病因及诱发因素。

4.Evolution of disease.5.Associated symptoms.6. Treatment and its effects7. General condition, especially the dietary ['daɪətərɪ]habit 饮食的习惯它包括以下几个方面：1.疾病的发生和持续时间。

2.主要症状，部位和特点3.病因和诱因。

4.疾病的演变过程。

5.伴随症状。

6.治疗及效果7.一般情况，特别是饮食习惯4.既往史Past history: Health condition and disease which the patient suffered before the present illness.I nfectious disease，surgery，allergy are essential part of the case history. 既往史：患者在现病前的健康状况和疾病。

传染病史，手术史，过敏史是既往史的重要组成部分。

5.family history 家族史Systems review: 系统回顾1. A thorough evaluation of the past and present status of each body system1.对每个人身体系统的过去和现在状况的彻底评估2. A double check to prevent omission of significant data relative to the present illness2.双重检查以防止遗漏与当前疾病相关的重要数据Personal history: It includes those relating to smoking and alcoholic beverages[be'vərɪdʒɪz](duration and amount), sedatives['sedətɪvz] , social history, profession and working condition. 个人史：它包括吸烟及酒精饮料（持续时间及数量），镇静剂，社交史，职业和工作环境。

Marital history: This review includes data concerning the health of the mate, the number of children and their physical status.婚姻史：本次回顾数据包含配偶的健康状况，子女数量和身体情况。

Menstrual [ˈmenstruəl] history and childbearing [ˈtʃaɪldbeərɪŋ] history: It applies to women only. It should include the menarche[mə'nɑ:ki:]age and her childrens health status.月经史和生育史：仅适用于女性，包括初潮年龄和子女的健康状况。

Family history: It inquires the disease of patient's first relative which might be hereditary, such as heart disease, hypertension, diabetes,家族史：查询病人第一亲属可能遗传的疾病，如，心脏病，高血压，糖尿病等。

重点词汇：Twofold双重的，两倍的，相当于doublethorough evaluation全面评估，万能词组，很多场合都可以用。

significant data 有意义的数据，这是对于数据的一个高配的形容，可以多用。

physical status 体格状态，用physical生理性状态，更专业。

病例回顾Case review定义Defination高危因素High risk factor临床表现Clinical manifestation辅助检查Auxiliary inspection治疗原则therapy principle of treatment General treatment medical treatement预后prognosis并发症complication常见症状Common symptoms：发热have a fever寒战shiver咳嗽cough咳痰expectoration腹痛abdominal pain 上腹epigastrium 下腹hypogastrium剑突下subcostal 脐周peri - umbilicus pain that typically begins around your naveright lower quadrant abdominal pain 右上腹痛腹胀恶心Nausea呕吐Vomiting黄疸Jaundice腹泻Diarrhea皮肤瘙痒Itchy skin Skin scratch厌油腻Anaerobic greasy食欲不振loss of appetite反酸烧心黑便呕血便血腹水水肿急性胰腺炎相关pancreas /'pænkrɪəs/ 胰腺;acute/chronic pancreatitis/,pænkrɪə'taɪtɪs/mild/moderately severe/severe acute pancreatitisMAP/MSAP/SAPcarcinoma /,kɑːsɪ'nəʊmə/ of pancreaslocal injury 本身的损害systemic inflammatory /ɪn'flæmət(ə)rɪ/ response syndrome(SIRS)全身炎症反应综合征abdominal [æbˈdɒmɪnl] pain 腹痛lumbodorsal [lʌ'bəʊdɔ:sl] pain 腰背部疼lumbar /'lʌmbə/腰部的dorsal/'dɔrsl/ 背部的nausea/'nɔzɪə/ 恶心vomit /'vɒmɪt/ 呕吐amylase/'æmɪleɪz/ 淀粉酶lipase /'lɪpeɪz/ 脂肪酶organ failure 器官衰竭necrotize/'nekrətaiz/ 坏死pancreatic /,pænkrɪ'ætɪk/ and/or peripancreatic necrosis/ne'krəʊsɪs/ biochemical evidence 生化指标radiographic evidence of pancreatitis on cross-sectional imaging 胰腺炎的横断面影像学表现nutritional support 营养支持enteral /'entərəl/ feeding 肠内enteral/parenteral /pə'rɛntərəl/ nutrition 肠内/肠外营养acute biliary/'bɪlɪərɪ/ pancreatitis 急性胆源性胰腺炎cholangitis/,kɔlən'dʒaitis/ 胆道炎、胆管炎cholecyst/'kɒlɪsɪst/ 胆囊cholecystitis 胆囊炎cholecystectomy /,kɒlɪsɪs'tektəmɪ/胆囊切除术ERCP：endoscopic(/,endəs'kↄpɪk/经内镜的) retrograde (/'retrəgreɪd/逆行的) cholangiopancreatography 英[kəʊlədʒaɪɒpæŋkr'ɪætɒɡər](胆道胰腺造影)complication of pancreas 胰腺的并发症pancreatic/,pænkrɪ'ætɪk/ fistula /'fɪstjʊlə/ 胰瘘pancreatic and/or peripancreatic abscess /'æbsɪs/ 胰腺或胰周脓肿pancreatic pseudocyst /'(p)sju:dəusist/ 胰腺假性囊肿abdominal [æbˈdɒmɪnl]compartment syndrome 腹腔间隔室综合征pancreatic sinistral (/'sɪnɪstr(ə)l/左的)portal hypertension (PSPH)胰源性左门静脉高压radiographic [ˌreɪdɪəʊ'græfɪk] evidence 影像学依据necrotizing ['nekrətaɪzɪŋ] pancreatitis 坏死性胰腺炎prophylactic( /,prɒfɪ'læktɪk/ 预防性的）antibiotics. 预防性应用抗生素acute biliary pancreatitis 急性胆源性胰腺炎cholangitis(/,kɔlən'dʒaitis/胆管炎)enteral rather than parenteral nutrition.nasogastric(/,neizəu'ɡæstrik/鼻饲的,鼻胃管) or nasoenteral route. cholecystectomy(/,kɒlɪsɪs'tektəmɪ/胆囊切除术)辅助检查Hepatobiliary B-ultrasound 肝胆B超肝胆脾CT全腹部CT胸部CT肝脏核磁共振头部CT头部核磁腹部X线转氨酶Liver enzyme levels白蛋白胆红素Bilirubin胆汁酸bile acid total bile acid肌酐尿素氮凝血酶原时间凝血酶原时间活动度消化科常见疾病Intrahepatic cholestasis of pregnancy（ICP)gestational complication 妊娠并发症perinatal mortality 围生期死亡率;unified opinion onChronic hepatobiliary basic diseaseshepatitis Cnon-alcoholic cirrhosisgallstones or cholecystitisnon-alcoholic pancreatitishistory of intrahepatic cholestasis induced by oral contraceptives artificial insemination pregnancymild fatty spasmsSerumhepatocyte injury.Initial Management of Acute Pancreatitis。