英语病历
医学英语病历
·admit (discharge) date[入院（出院）日期]
·Length of stay [住院天数]
·guarantor name [担保人姓名]
·next of kin or person to notify[需通知的亲属姓名]
·relation to patient[与病人关系]
*>20% blood volume lost [>20%血容量丢失]
*cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素
<8]
*chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者]
Physical Findings[阳性体征]
Lab/X-ray Findings[化验及放射报告]
Hospital Course[住院诊治经过]
Condition[出院状况]
Disposition[出院去向]
Medications[出院用药]
Prognosis[预后]
Special Instruction to the Patient(diet, physical activity)[出院指导（饮食，活
·secondary diagnosis[次要诊断]
·adverse reactions (complications)[副作用（合并症）]
·incision type[切口类型]
·healing course[愈合等级]
·operative (non-operative) procedures[手术（非手术）操作]
英语病历
1 病历case histroy一般事项date of admission /marital status /present address /correspondence / occupatio n主诉chief complaints现病史present illness / history of present illness既往史past medical history家族史family history个人病史personal history / social history曾用药物medications过敏史allergies系统回顾system review / review of system体检physical examination一般资料physical data 生理指标physical signs一般状况或全身状况general appearance头眼与耳鼻喉head ,eyes,ear,nose,throat ,略作heent.胸部与心肺CHEST,heart,and lungs腹部abodoms四肢extremities神经系统nervous system,Neurological,略作CNC或Neuro,骨骼肌系统Musculoskeletal泌尿生殖系统Genitourinary化验室资料laboratory data/ studies /diagnosis血液检查blood test化学7项指标chem.-7心脑电图electrocardiogram / electroencephalogram , 略作EKG/EEGX线检查与x光片X-ray examination, x-ray slides,计算机X线断层扫描与核磁共振扫描资料computerized x-ray tomography and nuclear mag netic resonance spectroscopy dta. CT AND NMR其他检查资料other lab data印象与诊断impression and diagnosis住院治疗情况hospital course出院医嘱discharge instructions / recommendations出院后用药discharge medications2 看病时用英文1) 一般病情:He feels headache, nausea and vomiting. (他覺得頭痛、噁心和想吐。
病历英语作文最简单三个步骤
病历英语作文最简单三个步骤Writing a Medical Case Report in English: Three Simple Steps撰写病历英语作文的三个简单步骤Step 1: Collect and Organize Your InformationFirstly, gather all the necessary data related to the patient"s medical history, including the chief complaint, history of present illness, past medical history, family history, and any relevant examination anize this information in a logical sequence to ensure a coherent narrative.第一步：收集和组织信息首先，收集与患者病史相关的所有必要数据，包括主诉、现病史、既往史、家族史以及任何相关的体检发现。
将这些信息按逻辑顺序组织起来，确保叙述连贯。
Step 2: Use Clear and Concise LanguageWhen drafting the medical case report, it is crucial to employ clear and concise language.Avoid using complex medical jargon that might confuse the reader.Instead, aim for simplicity while maintaining accuracy.Remember to use appropriate medical terms and describe symptoms and findings in a precise manner.第二步：使用清晰简洁的语言在撰写病历报告时，使用清晰简洁的语言至关重要。
英语病历作文格式模板
英语病历作文格式模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。
A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。
A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。
A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。
英语简要病历报告作文
英语简要病历报告作文Title: Patient Medical Report: A Case of Respiratory Infection。
Date: April 16, 2024。
Patient Information:Name: [Patient Name]Age: [Age]Gender: [Gender]Date of Admission: [Date]Admitting Physician: Dr. [Physician Name]Chief Complaint:The patient presents with symptoms of cough, fever, shortness of breath, and fatigue.History of Present Illness:The patient, [Patient Name], a [Age]-year-old [Gender], presented to the emergency department with complaints of cough, fever, shortness of breath, and fatigue for the past five days. The cough was productive, with yellowish-green sputum. The fever was intermittent and associated with chills. The patient also reported experiencing mild chest pain exacerbated by coughing.Past Medical History:The patient has a past medical history significant for asthma, for which they use an inhaler as needed. There are no known allergies to medications.Medications:The patient takes [Medication Name] for asthma asneeded.Social History:The patient is a non-smoker and denies any history of alcohol or illicit drug use. They work as a [Occupation] and have no recent travel history.Family History:There is no significant family history of respiratory illnesses.Physical Examination:On physical examination, the patient was febrile with a temperature of [Temperature], tachycardic with a heart rate of [Heart Rate], and tachypneic with a respiratory rate of [Respiratory Rate]. Oxygen saturation was [Oxygen Saturation]% on room air. Lung auscultation revealed coarse crackles in the lower lung fields bilaterally. There was no evidence of cyanosis, clubbing, or peripheral edema. 。
医学英语病历书写重点
Case History 病史In-Patient Case History 住院病历Items of Case History1. General Data, Biographical Data 一般项目2. Chief Complaints (C. C.) 主诉3. Present Illness (P. I.) 现病史4. Past (Medical) History (P. H.) 既往病史5. Personal History (Per. H.)/ Social History 个人史/社会史6. Family History (F. H.) 家族史7. Medications 曾用药物8. Allergies 过敏史9. System Review, Review of Systems 系统回顾10. Physical Examination (P. E.) 体格检查/查体11. Laboratory Data 实验室与其他检查/检查资料12. Impression (Imp.) (Diagnosis) 诊断13. Hospital Course 住院治疗情况记录14. Discharge Instructions/ Recommendations出院医嘱15. Discharge Medications 出院后用药General Data, Biographical Data 一般项目Reliability (病历可靠性):Reliable(可靠)/ Not Entirely(不完全可靠)/Not Clearly Defined (不够准确)/Confused and Uncertain (混乱不清)/ Unobtainable (无法获得)Supplier/ Complainer of History (供史者/病史陈述者):Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ NeighborChief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。
英语大病历模板
英文大病例写作示例时间:2007-06-04 17:19来源:中国医师协会作者: 点击: 355 次 ?撰写大病例是实习医师与住院医师的日常工作，也是上级医师作进一步诊断治疗的原始依据，国外的英文大病例并无统一格式，但是基本内容大致相仿，本节介绍的许多医疗记录的词汇值得借鉴。
Details个人资料Name: Joe Bloggs(姓名：乔。
伯劳格斯)Date: 1st January 2000（日期：2000年1月1日）Time: 0720(时间：7时20分)Place: A&E（地点：事故与急诊登记处）Age: 47 years（年龄：47岁）Sex: male（性别：男）Occupation: HGV(heavy goods vehicle ) driver（职业：大型货运卡车司机）PC(presenting complaint)（主诉）4-hour crushing retrosternal chest pain（胸骨后压榨性疼痛４小时）HPC(history of presenting complaint)（现病史）Duration: persistent since onset（间期：发病起持续至今）Severe: “worst pain ever had”（严重性：“从未痛得如此厉害过）Relieving/exacerbating factors缓解与恶化因素GTN(glyceryl trinitrate) provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.（硝酸甘油平时能在数分钟内缓解疼痛，但本次无效，无其它缓解和恶化因素。
）Associated symptoms相关症状Nausea, vomiting×2, sweating, dizzy（恶心、呕吐2次、出汗、眩晕）1997:external chest tightness and dyspnea initially controlled atenolol.1997年：出现胸外疼痛与呼吸困难，最终经服atenolol控制。
医护英语病历作文格式
医护英语病历作文格式Title: Proper Format for Medical Records in English。
In the realm of healthcare, maintaining accurate and organized medical records is paramount for effective patient care and legal documentation. Whether it's in hospitals, clinics, or other healthcare facilities, adhering to a standardized format ensures clarity, consistency, and confidentiality. Here, we delve into the essential components and formatting guidelines for medical records composed in English.1. Patient Information:Begin with the patient's demographic details including full name, date of birth, gender, address, and contact information.Include unique identifiers such as medical record number or social security number for easy reference.2. Chief Complaint:Clearly state the reason for the patient's visit in their own words or as reported by accompanying individuals.Provide details regarding the onset, duration, severity, and any associated symptoms.3. Medical History:Document the patient's past medical conditions, surgeries, allergies, and ongoing medications.Include family history to assess genetic predispositions and potential hereditary conditions.4. Present Illness:Describe the current health status, focusing on the chronological progression of symptoms and relevant events leading up to the consultation.Use precise language and medical terminology to convey information accurately.5. Physical Examination:Record findings from the physical assessmentincluding vital signs, general appearance, organ systems examination, and any abnormalities detected.Include measurements such as height, weight, blood pressure, and temperature.6. Diagnostic Tests and Results:List all diagnostic procedures conducted along with the date, type, and results.Attach copies of laboratory reports, imaging studies, and other relevant investigations for reference.7. Assessment and Diagnosis:Formulate a concise summary of the patient's condition based on the history, examination, and diagnostic findings.Provide a clear diagnosis using standard medical terminology and codes as applicable.8. Treatment Plan:Outline the recommended course of action including medications prescribed, procedures scheduled, referrals made, and patient education provided.Specify dosage, frequency, duration, and any special instructions for medications and therapies.9. Progress Notes:Document all interactions with the patient including follow-up visits, telephone consultations, and correspondence with other healthcare providers.Record changes in the patient's condition, response to treatment, and any adverse reactions experienced.10. Consent Forms and Legal Documents:Ensure proper documentation of informed consent for treatments, surgeries, and participation in research studies.Maintain compliance with legal requirements regarding patient confidentiality, release of information, and medical record retention.11. Signature and Authentication:Endorse each entry with the signature of the healthcare provider responsible for the assessment and treatment.Include the date and time of documentation to establish the chronological order of events.12. Organizational Standards:Adhere to institutional protocols and regulatory guidelines governing medical record documentation.Use electronic health record (EHR) systems efficiently to streamline data entry, retrieval, and sharing.In conclusion, adhering to a standardized format for medical records in English ensures comprehensive documentation, facilitates communication among healthcare providers, and upholds patient confidentiality and legal compliance. By following these guidelines meticulously, healthcare professionals contribute to the delivery of quality care and the maintenance of accurate healthcare records.。
Admission Notes英文版病例 英语病历
Admission Notes (2)A 60-year-old married male was admitted on March 10,2010, with a two-month palpitation and a thoracalgia.Since this March, the patient has frequently felt palpitations a chest pain upon physical exertion, the latter radiating into the left shoulder and arm. One attack lasts about five minutes. He has a feeling of suffocation. It seems as if something heavy were pressing hard on his chest. He has a slight cough and expectorates a little mucous sputum during the attack.. Because he has not had any treatment before, the symptoms mentioned above have also deteriorated this week and his legs have been swollen as well, he came to the hospital for medical treatment.During his illness, he has been feeling weak but he has had a goodappetite, and his bowel motions and micturition have remained normal.He said that he had been perfectly healthy and had never had rheumatic fever or heart trouble previously.There is nothing particular in his family medical history.PE T: 36.7”C; P:100/min. R:20/min.;BP:140/80mmHg(19—11kPa).Well developed and nourished. In his right mind and in voluntary position. No dyspnea or cyanosis detected. No eruption or purpura over skin. Superficial lymph nodes impalpable. Skull and head organs not abnormal. Neck soft and supple and free of venous engorgement. Trachea in midline. Thyroid not enlarged. Chest symmetrical. Lungs clear. Heart enlarged and leftward without irregular beats. Heart rate 100/min. A grade—IIIharsh blowing systolic murmur heard at the apical area with no thrill felt or diastolic murmur heard. Abdomen flat with no tenderness. Liver felt 2 fb below costal margin. Hepatojugular reflux negative. Spleen not palpable. No shifting dullness over abdomen heard. Slight edema in both ankles present. Bilateral knee jerk reflexes active. No pathological neural reflex found.Chest fluoroscopy reveals general cardiac enlargement.ECG shows:1.sinus rhythm2.left ventricular hypertrophy3.chronic coronary insufficiency Diagnosis: Coronary Heart Disease Left V entricular HypertrophyAngina Pectoris Signature: Date:。
医学英语病历写作范文
医学英语病历写作范文Chief Complaint: Patient presents with chest pain and shortness of breath for 3 days.History of Present Illness: The patient, a 55-year-old male, reports experiencing sudden onset of chest pain 3 days ago. The pain is described as sharp and crushing, radiating to the left arm. He also reports associated shortness of breath and diaphoresis. The symptoms are aggravated with physical activity and alleviated with rest. There is no history of similar episodes in the past.Past Medical History: The patient has a history of hypertension and hyperlipidemia. He is on regular medications including amlodipine and atorvastatin.Family History: The patient's father had a history of myocardial infarction at the age of 60. His mother has hypertension and diabetes.Social History: The patient is a non-smoker and denies alcohol or recreational drug use. He is currently employed as a manager and reports moderate stress at work.Review of Systems: The patient denies any recent weight changes, fever, or chills. There is no history of cough, sputum production, or hemoptysis. He denies any gastrointestinal symptoms such as nausea, vomiting, or abdominal pain.Physical Examination:- Vital signs: Blood pressure 140/90 mmHg, heart rate 90 bpm, respiratory rate 20 breaths per minute, oxygen saturation 96% on room air.- General: The patient appears uncomfortable and diaphoretic.- Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops. Capillary refill time is less than 2 seconds.- Respiratory: Clear breath sounds bilaterally, no wheezing or crackles.Assessment and Plan:1. Rule out acute coronary syndrome: The patient's presentation is concerning for acute coronary syndrome given the symptoms of chest pain, shortness of breath, anddiaphoresis. ECG and cardiac enzymes will be obtained to evaluate for myocardial ischemia.2. Blood pressure management: The patient's blood pressure is elevated, and optimization of antihypertensive medications will be addressed.3. Lipid management: Given the patient's history of hyperlipidemia, lipid panel will be obtained to assess for dyslipidemia and adjust medications as needed.4. Stress management: The patient's moderate stress at work will be addressed through counseling and potential referral to a stress management program.中文病历：主诉：患者因胸痛和呼吸急促已3天。
英语写病历作文模板
英语写病历作文模板 Patient History Template。
英文回答：General Information。
Name:Age:Gender:Occupation:Address:Phone number:Emergency contact:Medical History。
Past medical history: List any previous illnesses, surgeries, hospitalizations, or accidents.Family medical history: Note any history of chronic diseases, such as heart disease, cancer, or diabetes, in the patient's family.Allergies: List any known allergies to medications, foods, or other substances.Medications: List all current medications, including prescription drugs, over-the-counter medications, and herbal supplements.Social history: Discuss the patient's lifestyle, including diet, exercise, smoking, alcohol use, and drug use.Present Illness。
Chief complaint: State the patient's primary reasonfor seeking medical attention.History of present illness: Describe the onset, duration, severity, and progression of the patient's symptoms.Physical Examination。
四年级英语病历范文
四年级英语病历范文Patient Name: Zhang SanAge: 10 years oldDate of Visit: October 10th, 2023Chief Complaint:The patient complains of a sore throat, cough, and runny nose for the past three days.History of Present Illness:The patient's symptoms started three days ago with a sore throat, followed by a cough and runny nose. The cough is dry and persistent, and the patient has been experiencing some difficulty swallowing due to the sore throat. There is no history of fever, chills, or ear pain. The patient's appetite has decreased, and there is a mild decrease in energy levels.Past Medical History:The patient has a history of seasonal allergies, with symptoms of sneezing and itchy eyes during the spring andfall seasons. There is no history of asthma or other chronic respiratory conditions.Family History:There is no significant family history of respiratory illnesses or other chronic conditions.Medications:The patient is not currently taking any medications.Allergies:The patient has no known drug allergies.Review of Systems:- Constitutional: Decreased appetite and energy levels - Respiratory: Sore throat, cough, runny nose- Gastrointestinal: No nausea, vomiting, or diarrhea - Musculoskeletal: No joint pain or swellingPhysical Examination:- Vital Signs: Temperature 98.6°F, pulse 80 beats per minute, respiratory rate 20 breaths per minute, blood pressure 110/70 mmHg- General: The patient appears fatigued, but alert and oriented- Head and Neck: Erythematous pharynx, no tonsillar exudates, clear nasal discharge- Respiratory: Lungs clear to auscultation bilaterally - Cardiovascular: Regular rate and rhythm, no murmurs or gallops- Abdomen: Soft, non-tender, non-distendedAssessment:Based on the patient's history and physical examination, the likely diagnosis is an upper respiratory tract infection, possibly viral in nature.Plan:1. Symptomatic treatment for sore throat and cough, including acetaminophen for pain and discomfort2. Encourage increased fluid intake and rest3. Monitor for any signs of worsening symptoms, such as persistent high fever or difficulty breathing4. Follow up in three days if symptoms do not improve or worsen中文回答：患者张三，10岁，主诉三天来咽喉痛、咳嗽和流鼻涕。
英文病历对照
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
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
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 ）
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
英语病历白班交班报告范文
英语病历白班交班报告范文English Medical Record Day Shift Handover Report.Introduction.As the day shift comes to an end, it is imperative to provide a comprehensive handover report to ensure the continuity of patient care and the efficient transition of responsibilities to the incoming night shift. This report outlines the key events, observations, and actions taken during the day shift, focusing on the patients' conditions, treatments administered, and any pending or planned interventions.Patient Overview.During the day shift, we had a total of 25 patients under our care, ranging from inpatient admissions to outpatient consultations. The patients' conditions ranged from mild to critical, with a focus on monitoring andmanaging chronic conditions, acute episodes, and post-surgical recoveries.Admissions and Discharges.Three new patients were admitted to the hospital during the day shift. Patient A, a 65-year-old male with a history of chronic obstructive pulmonary disease (COPD), was admitted with an acute exacerbation. Patient B, a 42-year-old female, presented with a suspected stroke. Patient C, a 10-year-old child, was admitted for a routine surgical procedure.Two patients were discharged during the day shift. Patient D, a 70-year-old male with stable angina, was discharged after a successful course of treatment. Patient E, a 35-year-old female with a minor fracture, was discharged following the removal of casts and mobilization.Key Observations and Interventions.Patient A: The patient's respiratory status wasmonitored closely. Nebulization and oxygen therapy were administered as needed. His condition improved gradually, and he was able to ambulate with minimal assistance.Patient B: An urgent neuroimaging study was ordered, which revealed a minor ischemic stroke. The patient was started on anticoagulant therapy and was monitored for any neurological changes.Patient C: The surgical procedure was uneventful, and the patient recovered well. Post-operative analgesia and antibiotics were administered as per protocol.Medication Administration.All patients received their scheduled medications on time. Additional medications were administered as needed for symptoms control or as prescribed by the attending physicians. Close attention was paid to drug interactions and side effects, ensuring patient safety.Laboratory and Diagnostic Tests.Routine laboratory tests, including blood counts, electrolytes, and biochemistry profiles, were performed for inpatients. Diagnostic tests such as X-rays, ECGs, and ultrasound scans were conducted as required for patient management. All results were reviewed and acted upon by the attending team.Patient Education and Counseling.Patient education sessions were conducted on chronic disease management, medication adherence, and lifestyle modifications. Counseling was provided for emotional support and addressing patient concerns.Pending and Planned Interventions.Patient A: A follow-up pulmonary function test is scheduled for tomorrow to assess the patient's progress.Patient B: The patient will require continuous monitoring for neurological changes and regular checks onanticoagulant therapy.Patient C: Post-surgical wound care and follow-up visits are scheduled for the next few days.Conclusion.The day shift has been eventful, with multiple admissions, discharges, and interventions. The team has worked diligently to ensure the best possible care for our patients. It is crucial for the incoming night shift to be well-informed and prepared to continue the care seamlessly. We look forward to a smooth transition and continued success in patient care.。
急性化脓性扁桃体的中医病历英语范文
急性化脓性扁桃体的中医病历英语范文Chief Complaint: Acute purulent tonsillitis.History of Present Illness:The patient is a 20-year-old male who presents with a 2-day history of sore throat, difficulty swallowing, fever, chills, and headache. He rates the pain in his throat as8/10. He has no cough, runny nose, or congestion. He denies any sick contacts.Past Medical History:The patient has no significant past medical history.Medications:The patient is not taking any medications.Allergies:The patient has no known drug allergies.Social History:The patient is a student who lives in a dormitory. He is not a smoker or drinker.Family History:The patient's family history is unremarkable.Physical Examination:General: The patient is in moderate distress. He is afebrile, with a pulse of 100 beats per minute, respirations of 16 breaths per minute, and blood pressure of 120/80 mmHg.HEENT: The patient's head and neck are supple with no masses or tenderness. His ears are normal. His nose is clear. His oropharynx is erythematous and edematous, withpurulent exudate on the tonsils.Neck: The patient's neck is supple with no masses or tenderness. His thyroid is normal.Cardiovascular: The patient's heart is regular with no murmurs, gallops, or rubs.Pulmonary: The patient's lungs are clear to auscultation bilaterally.Abdomen: The patient's abdomen is soft, non-tender, and non-distended. His liver and spleen are not palpable.Extremities: The patient's extremities are warm and well-perfused. His pulses are palpable.Neurological: The patient is alert and oriented x3. His cranial nerves are intact. His motor and sensory examinations are normal.Differential Diagnosis:Acute viral tonsillitis.Acute bacterial tonsillitis.Streptococcal pharyngitis.Infectious mononucleosis.Laboratory Tests:Rapid strep test: Positive.White blood cell count: 12,000/μL.Absolute neutrophil count: 8,000/μL.Treatment Plan:Amoxicillin-clavulanate 875 mg/125 mg every 12 hours for 10 days.Acetaminophen 500 mg every 6 hours as needed for fever and pain.Gargle with warm salt water every 2 hours.Rest and fluids.Follow-Up:The patient will be seen in follow-up in 1 week.Impression:Acute purulent tonsillitis due to Streptococcus pyogenes.Notes:The patient was diagnosed with acute purulenttonsillitis due to Streptococcus pyogenes based on the presence of a positive rapid strep test and a history of sore throat, difficulty swallowing, fever, and chills. Thepatient was treated with amoxicillin-clavulanate, acetaminophen, and instructions to gargle with warm salt water. The patient will be seen in follow-up in 1 week.。
关于三个病人病历的报告英语作文
关于三个病人病历的报告英语作文{z}Title: Report on the Medical Records of Three PatientsIntroduction:This report aims to provide a comprehensive overview of the medical records of three patients.The patients" backgrounds, diagnoses, and treatments will be discussed in detail.Patient 1:ame: Sarah JohnsonAge: 35 yearsGender: FemaleMedical History:Sarah has a history of diabetes mellitus type 2.She has been suffering from the condition for the past 5 years.She has been on insulin therapy and a balanced diet.Complaints:Sarah visited the hospital due to persistent vomiting and abdominal pain.She also complained of dizziness and weakness.Diagnosis:Upon examination and laboratory tests, Sarah was diagnosed with diabetic ketoacidosis (DKA).The high blood sugar levels and the presence of ketones in her urine confirmed the diagnosis.Treatment:Sarah received intravenous fluids to correct the dehydration.Insulin therapy was adjusted to lower her blood sugar levels.Close monitoring of her blood sugar levels and urine ketone levels was done.Patient 2:ame: Mark ThompsonAge: 45 yearsGender: MaleMedical History:Mark has a history of hypertension and myocardial infarction.He has been on medication for the past 2 years to manage his blood pressure and prevent further heart complications.Complaints:Mark visited the hospital with complaints of severe chest pain and shortness of breath.He also experienced sweating and nausea.Diagnosis:Upon evaluation, Mark was diagnosed with unstable angina.An electrocardiogram (ECG) revealed ST-segment depression, indicating myocardial ischemia.Treatment:Mark was stabilized with intravenous medications to relieve chest pain and improve blood flow to the heart.He was also given medications to lower his blood pressure and reduce the risk of further heart attacks.Patient 3:ame: Emily WilsonAge: 28 yearsGender: FemaleMedical History:Emily has a history of irritable bowel syndrome (IBS).She experiences periodic abdominal pain and diarrhea.Complaints:Emily sought medical attention due to severe abdominal cramps and frequent bowel movements.She also complained of bloating and flatulence.Diagnosis:Upon examination and laboratory tests, Emily was diagnosed with acute appendicitis.An ultrasound revealed an enlarged appendix.Treatment:Emily underwent emergency appendectomy to remove the inflamed appendix.She was given antibiotics to prevent感染and manage any postoperative complications.Conclusion:This report highlights the medical records of three patients with different health conditions.Sarah was diagnosed with diabetic ketoacidosis, Mark experienced unstable angina, and Emily underwentappendectomy due to acute appendicitis.Timely diagnoses and appropriate treatments were provided to improve their health conditions.。
住院病历英语作文
住院病历英语作文English:The hospitalization medical record serves as a crucial document in the continuum of patient care, encapsulating vital information about the patient's condition, treatment plan, and progress throughout their hospital stay. It typically includes demographic details, such as the patient's name, age, and contact information, alongside a comprehensive medical history detailing any pre-existing conditions, allergies, and medications. The presenting complaint and pertinent physical examination findings are documented, followed by diagnostic test results, including laboratory investigations, imaging studies, and other specialized tests. The treatment regimen, encompassing medications, procedures, surgeries, and therapeutic interventions, is meticulously recorded, along with any adverse reactions or complications encountered during the hospitalization. Moreover, the medical record serves as a communication tool among healthcare professionals, ensuring continuity of care and facilitating interdisciplinary collaboration. Ultimately, it plays a pivotal role in clinical decision-making, quality assessment, and medico-legal matters, serving as a repository of essential clinicalinformation essential for optimal patient management and healthcare delivery.Translated content:住院病历是患者医疗过程中不可或缺的文件，记录了患者在住院期间的病情、治疗方案和进展等重要信息。
关于病历的作文英语
关于病历的作文英语In the realm of healthcare, medical records are indispensable documents that serve as a comprehensive account of apatient's medical history, diagnoses, treatments, and outcomes. They are crucial for several reasons, which I will elaborate on in this essay.First and foremost, medical records provide a detailed account of a patient's health journey, which is invaluablefor continuity of care. When a patient consults a new physician or is admitted to a hospital, the medical records offer a quick and thorough understanding of their health status. This aids healthcare professionals in making informed decisions about the patient's treatment plan.Secondly, the records facilitate the process of diagnosis. By reviewing a patient's medical history, doctors can identify patterns, rule out certain conditions, and make more accurate diagnoses. This is particularly important in cases where symptoms are nonspecific or where a patient has a complex medical profile.Moreover, medical records are essential for monitoring the effectiveness of treatments. They allow healthcare providers to track the progression of a disease, the response to medications, and the success of surgical interventions. This data is critical for adjusting treatment strategies and ensuring the best possible outcomes for patients.In addition, medical records play a significant role in research and epidemiology. They provide researchers with valuable data that can be used to study the prevalence of diseases, the effectiveness of treatments, and the impact of various factors on health outcomes. This information is vital for advancing medical knowledge and improving public health.Furthermore, medical records are a legal requirement in many countries. They serve as evidence in medical malpractice cases and are necessary for insurance claims and reimbursements. They also protect healthcare providers from potential legal issues by documenting the standard of care provided.Lastly, with the advent of electronic health records (EHRs), the accessibility and sharing of medical information have improved significantly. EHRs enable seamless communication between healthcare providers, reduce medical errors, and enhance patient safety.In conclusion, medical records are a cornerstone of modern healthcare. They ensure the continuity of care, facilitate accurate diagnoses, monitor treatment effectiveness, support medical research, fulfill legal requirements, and enhance patient safety through the use of EHRs. As such, maintaining accurate and up-to-date medical records is a fundamental responsibility of healthcare providers and a critical component of quality patient care.。
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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 andcommunicable 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mmHgGeneral 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cmreaction 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cmDusculation: 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 P2S3 无有S4 无有A2 P2Extra 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(+)(-) othersKernig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-rayX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记录日期补充下：第一章病人身份[Identification] • [Name] 姓名• [Sex] 性别• [Ag e] 年龄• [Occupation]职业• [Date of birth] 出生日期• [Marriage （Marital status）] 婚姻• [Race] 民族• [P lace of birth (Birth place)] 籍贯• [Identification No.(code of ID card No.)] 身份证号码•[Department of work and TEL. No. (Unit and Business phone No.)] 工作单位及电话• [Home address and phone No.] 家庭住址及电话• [Post code] 邮政编码• [Person to not ify (Correspondent) and phone No.] 联系人及电话• [Source (Complainer;offerer;supplier; provider) of history] 病史陈术者• [Reliability of history] 病史可*程试• [Medical security (Type of payment)] 医疗费用• [Type of admission (Patient condition)] 住院类别（入院时病情）• [Medical record No.] 病历号• [Clinic diagnosis] 门诊诊断• [Date of admission (admission date)] 入院日期• [Date of record] 记录日期1、年龄的表示方法（以36岁为例）•36 years old (y/o) •Age 36 •36 year-old •The age of 36 •36 ye ars of age 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[Retired worker] •农民[Farmer (peasant)] •干部[Leader (cadre)] •行政人员[administrative personnel (staff)] •职员[staff member] •商人[Trader (Businessman)] •教师[Teacher] •学生[Student] •医生[Docto r] •药剂师[Pharmacist] •护士[Nurse] •军人[Soldier] •***[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] •***人[Japanese] •英国人[Britisher] 5、医疗费用的表示方法• [Self pay (Individual medical care)] 自费• [Governm ent insruance (Public medical care)] 公费• [Insurance] 保险• [Local insurance] 本地医保• [Non-local in surance] 外地医保• [Labor protestion care] 劳保6、婚姻状况的表示方法• [Married] 已婚• [Single (Unmarried)] 未婚• [Diverced] 离婚• [Widow] 寡妇• [Wi dower] 鳏夫7、病史可*程度的表示方法• [Reliable] 可* • [Unreliable] 不可* • [Not entir ely] 不完全可* • [Unobtainable] 无法获得8、住址的表示方法•[NO.3,Qing Chun Road Eas t,Hangzhou, Zhejiang] 浙江省杭州市庆春东路3号•[XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.] 浙江省诸暨市（县）城关镇新东村9、病史陈述者的表示方法• [Patient himself (herself)] 患者本人• [Her husband] 患者的丈夫• [His wife] 患者的妻子• [Patient`s colleague] 患者的同事• [Patient`s neighbor] 患者的邻居• [Patient `s Kin (Mother; Son; daughter;brother;Sister)] 患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹) • [Taximan] 出租车司机• [Traffic police] 交通*** 10、日期的表示方法•2002年10月1日[10-1-2002(10/1/2002; Oct.1,2002; Oct.lst,2002)](美国) •2002年10月1日[1-10-200 2(1/10/2002; 1 Oct.,2002; 1st of Oct.,2002)] (英国) 11、住院类别的表示方法• [Emergent(Emergency call)] 急诊• [Urgent] 危重• [Elective (General)] 一般（普通）12、入院时病情的表示方法• [Stable] 稳定• [Unstable] 不稳定• [Relative stable] 相对稳定• [Critical (Imminent)] 危重• [Fair (General)] 一般第二章主诉[Chief Complaint] 1、主诉的表示方法：症状+时间（Symptom+Time）•症状+for+时间如：[Chest pain for 2 hours] 胸痛2小时•症状+of+时间如：[Nausea and vomiting of three days` duration] 恶心呕吐3天•症状+时间+in duration 如：[Headache 1 month in duration] 头痛1月•时间+of+症状如：[Two-day history of fever] 发热2天2、常见症状• [Fever] 发热• [Pain] 疼痛• [Edema]水肿• [Mucocutaneous h emorrhage (bleeding)] 皮肤粘膜出血• [Dyspnea (Difficuly in b reathing;Respiratory difficulty;short of breath)] 呼吸困难• [Cough and expectoration (Sp utum;Phlegm)] 咳嗽和咯痰• [Hemoptysis] 咯血• [Cyanosis] 紫绀• [Palpitation] 心悸• [Chest discomfort] 胸闷• [Nausea (Retch;Dr y Vomiting)and Vomiting] 恶心和呕吐• [He matemesis (Vomiting of blood)] 呕血• [Hematochezia (Hemafecia)] 便血• [Diarrhea] 腹泻• [Constipation (Obstipation)] 便秘• [Vertigo (Giddiness; Dizziness)] 眩晕• [Jaundice (Icterus)] 黄疸• [Convulsion] 惊厥• [Disturbance of cons ciousness] 意识障碍• [Hemat uria] 血尿• [Frequent micturition,urgent micturition and dysuria] 尿频，尿急和尿痛• [Inc ontinence of urine] 尿失禁• [Retention of urine] 尿潴留（1）发热的表示方法• [Infective (Septic)fever] 感染性发热• [Non-infective (Aseptic)fever] 非感染性发热• [Dehydration (I nanition)fever] 脱水热• [Drug fever] 药物热• [Functional hypothermia] 功能性低热• [A bsorption fever] 吸收热• [Central fever] 中枢性发热• [Fever type] 热型▲[Continuous fever] 稽留热▲[Remittent fever] 驰张热▲[Intermittent fever] 间歇热▲[Undulant f ever] 波状热▲[Recurrent fever] 回归热▲[Periodic fever] 周期热▲[Irregular fever] 不规则热▲[Ephemeral fever] 短暂热▲[Double peaked fever] 双峰热• [Fever of und etermined(unknown) origin, FUO] 不明原因发热• [Rigor (shivering;chill;shaking chill;agu e)] 寒战• [Chilly Sensation (Fell chilly;cold fits;col dness)] 畏寒• [Ultra-hyperpyrexia] 超高热• [Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高热• [Moderate fever] 中度发热• [Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低热• [B ecome feverish (Have a temperature)] 发热• [Crisis] 骤降• [Lysis] 渐降• [Typhoid fev er] 伤寒热• [Rheumatic fever] 风湿热• [Cancerous fever] 癌性发热• [Fervescence peri od] 升热期• [Defervescence period] 退热期• [Persistent febrile period] 持续发热期（2）疼痛的表示方法• [Backache (Back pain)] 背痛• [Lumbago] 腰痛• [Headache] 头痛▲[Vasomotor headache] 血管舒缩性头痛▲[Post-traumatic headache] 创伤后头痛▲[Migrai ne headache] 偏头痛▲[Cluster headache] 丛集性头痛• [Chest pain] 胸痛• [Precardial pain] 心前区痛• [Retrosternal pain] 胸骨后痛• [Abdominal pain (Stomachache)] 腹痛•[Acrodynia (pain in limbs)] 肢体痛• [Arthrodyni a (Arthralgia)] 关节痛• [Dull pain] 钝痛• [Sharp pain] 锐痛• [Twinge pain] 刺痛• [Knife-like pain (Piercing pain)] 刀割（刺）样痛• [Aching pain] 酸痛• [Burning pain] 烧灼痛• [Colicky (Griping;cramp) pain] 绞痛• [Colic] 绞痛• [Bursting pain] 胀痛（撕裂痛）• [Hunger pain] 饥饿痛• [Tic pain] 抽搐痛• [Bearing-down pain] 坠痛• [Shock-like pain] 电击样痛• [Jumping pain] 反跳痛•[Tenderness pain] 触痛（压痛）• [Girdle-like pain] 束带样痛• [Wandering pain] 游走性痛• [Throbbing pain] 搏动性痛• [Radiating pain] 放射性痛• [Cramping pain] 痉挛性痛• [Boring pain] 钻痛• [I ntense pain] 剧痛• [Writhing pain] 痛得打滚• [Dragging pain]牵引痛• [Labor pain] 阵痛• [Cancerous pain] 癌性疼痛• [Referred pain] 牵涉痛• [Pe rsistent pain (Unremitting pain)] 持续性痛• [Constant pain] 经常性痛• [Intermittent pai n] 间歇性痛（3）水肿的表示方法• [Mucous edema (Myxedema)] 粘液性水肿• [Cardiac (Cardiogenic) edema] 心源性水肿• [Nephrotic (renal) edema] 肾源性水肿• [Hepatic edema] 肝源性水肿• [Alimentary (Nutritional) edema] 营养不良性水肿• [Angioneurotic edema] 血管神经性水肿• [Pitting] 凹陷性• [Nonpitting] 非凹陷性• [Localized (Local) edema] 局限性水肿• [Gen eralized edema (Anasarca)] 全身性水肿• [Hydrops] 积水• [Elephantiasic crus] 橡皮肿• [Cerebral(Brain) edema] 脑水肿• [Pulmonary edema (Hydropneumonia0] 肺水肿• [Hydrocephalus] 脑积水• [Edema of endoscrinopathy] 内分泌病性水肿• [Invisible (Recessive) edema] 隐性水肿• [Frank edema] 显性水肿• [Inflammatory edema] 炎性水肿• [Idiopathic edema] 特发性水肿• [Cyclical edema] 周期性水肿• [Ascites (Abdominal effusion;hydroperiotoneum)] 腹水• [Pleural effusion (Hydrothorax)] 胸水• [Pericardial effusion (Hydropericardium)] 心包积液• [Bronchoedema] 支气管水肿• [Sli ght (Mild)] 轻度• [Moderate] 中度• [Serious] 重度• [Transudate] 漏出液• [Exudate] 渗出液（4）呼吸困难的表示方法• [Cardiac dyspnea] 心原性呼吸困难• [Inspiratory] 吸气性• [Expiratory] 呼气性• [Mixed] 混合性• [Obstructive] 梗阻性• [Dyspnea at rest] 静息时呼吸困难• [Dyspnea on exertion] 活动时呼吸困难•[Dyspnea on lying down] 躺下时呼吸困难• [Paroxysmal nocturnal dyspnea,PND] 夜间阵发性呼吸困难• [Orthopnea] 端坐呼吸• [Asthma] 哮喘• [Cardiac asthma] 心源性哮喘• [Bronchial asthma] 支气管性哮喘• [Hyperpnea] 呼吸深快• [Periodic breathing] 周期性呼吸• [Tachypnea (Rapid or fast breathing;acce lerated breathing;short of breath)]气促• [Bradypnea (Slow breathing)] 呼吸缓慢• [Irregular breathing] 不规则呼吸（5）皮肤粘膜出血的表示方法• [Bleeding spots in the skin] 皮肤出血点• [Petechia] 瘀点• [Eccymosis] 瘀斑• [Purpura] 紫癜• [Splinter hemorrhage] 片状出血• [Oozing of the blood (Errhysis)] 渗血• [Blood blister (Hemophysallis)] 血疱• [Hemorrhinia (Nasal bleeding)] 鼻衄• [Ecchymoma] 皮下血肿（6）咳嗽与咯痰的表示方法• [Dry cough (Nonproductive cough;hacking cough)] 干咳• [Sharp cough] 剧咳• [Wet cough (Moist cough)] 湿咳• [Productive cough (Loose cough)] 排痰性咳• [Chronic cough] 慢性咳嗽• [Irritable cough] 刺激性咳嗽• [Paroxysmal cough] 发作性（阵发性）咳嗽• [Cough continually] 持续性咳嗽• [Spasmodic cough] 痉挛性咳嗽• [Whooping cough] 百日咳• [Winter cough] 冬季咳• [Wheezing cough] 喘咳• [Short cough] 短咳• [Distressed cough] 难咳• [S hallow cough] 浅咳• [Droplet] 飞沫• [Frothy sputum] 泡沫样痰• [Bloody sputum] 血痰• [Mucous (Mucoid) sputum] 粘液样痰• [Purulent sputum] 脓痰• [Mucopurulent sputum] 粘液脓性痰• [White (Yellow,green) sputum] 白（黄,绿）痰• [Fetid (Foul) sputum] 恶臭痰• [Iron-rust (Rusty) sputum] 铁锈色痰• [Chocolate coloured sputum] 巧克力色痰• [Thick sputum] 浓痰• [Thin sputum] 淡痰• [Viscous sputum] 粘痰• [Transparent sputum] 透明痰• [Much (Large amounts of) sputum] 大量痰• [Moderate amounts of sputum] 中等量痰• [Not much (Small amounts of ) sputum] 少量痰（7）内脏出血的表示方法• [Goldstein’s hemoptysis]戈耳斯坦氏咯血• [Massive hematemesis]大量呕血• [Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)]鼻衄• [Hematuria] 血尿• [Initial hematuria] 初血尿• [Idiopathic hematuria] 特发性血尿• [Painless hematuria] 无痛性血尿• [Terminal hem aturia] 终末性血尿• [Gross (Macroscopic) hematuria] 肉眼血尿• [Microscopic hematuria] 镜下血尿• [Hematuria in the whole process of urination] 全程血尿• [Gingival bleeding (Ulaemorrhagia;gum bleeding)] 牙龈出血• [Hematochezia] 便血• [Bloody stool] 血便• [Black stool (Melena)] 黑便• [Tarry stool] 柏油样便• [Bleeding following trauma] 外伤后出血• [Spontaneous bleeding] 自发性出血• [Bleeding Continuously] 持续出血• [Occult blood,OB] 隐血• [Hematobilia] 胆道出血• [Hemathorax] 血胸• [Hemarthrosis] 关节积血• [Hematocoelia] 腹腔积血• [Hematoma] 血肿• [Hemoper icardium] 心包积血• [Cerebral hemorrhage] 脑出血• [Subarachnoid hemorrhage(SAH)] 蛛网膜下腔出血• [Excessive (Heavy) menstrual flow with passage of clots] 月经量多伴血块• [Mild (Moderate) menses] 月经量少（中等）• [Painless Vaginal bleeding] 无痛性阴道出血• [Postcoital bleeding] 性交后出血•[Pulsating bleeding] 搏动性出血• [Post-operation wound hemorrhage] 术后伤口出血• [Excessive bleeding after denal extraction] 拔牙后出血过多（8）紫绀的表示方法• [Congenital cyanosis] 先天性紫绀• [Enterogenous] 肠源性• [Central] 中枢性• [Peripheral] 周围性• [Mixed] 混合性• [Acrocyanosis] 指端紫绀（9）恶心与呕吐的表示方法• [Vomiturition (Retching)] 干呕• [Feel nauseated] 恶心感• [Postprandial nausea] 饭后恶心• [Hiccup] 呃逆• [Sour regurgitation] 返酸• [Fecal (Stercoraceous) vomiting] 吐粪• [undigested food Vomiting] 吐不消化食物• [Bilious Vomiting] 吐胆汁（10）腹泻与便秘的表示方法• [Moning diarrhea] 晨泻• [Watery (Liquid)diarrhea] 水泻• [Mucous diarrhea] 粘液泻• [Fatty diarrhea] 脂肪泻• [Chronic (Acute)] 慢性（急性）• [Mild diarrhea] 轻度腹泻• [Intractable (Uncontrolled)diarrhea] 难治性腹泻• [Protracted diarrhea] 迁延性腹泻• [Bloody stool] 血梗• [Frothy sto ol] 泡沫样便• [Formless (Formed)stool] 不成形（成形）便• [Loose (Hard) stool] 稀（硬）便• [Rice-water stool] 米泔样便• [Undigested stool] 不消化便• [Dysenteric diarrhea] 痢疾样腹泻• [Inflammatory diarrhea] 炎症性腹泻• [Osmotic] 渗透性• [Secretory] 分泌性• [Malabsorption] 吸收不良性• [Lienter ic] 消化不良性• [Pancreatic diarrhea] 胰性腹泻• [Tenesmus] 里急后重• [Pass a stool (Have a passage; open or relax the bowel)] 解大便• [Have a call of nature] 便意• [Fecal incontinence (Copracrasia)] 大便失禁• [Functional constipation] 功能性便秘• [Organic constipation] 器质性便秘• [Habitual constipation] 习惯性便秘• [Have a tendency to be constipated] 便秘倾向（11）黄疸的表示方法• [Latent (occult) jaundice] 隐性黄疸• [Clinical jaundice] 显性黄疸• [Nuclear icterus] 核黄疸• [Physiologic icterus] 生理性黄疸• [Icterus simplex] 传染性黄疸• [Toxemic icterus] 中毒性黄疸• [Hemolytic] 溶血性• [Hepatocellular] 肝细胞性• [Obstructive] 阻塞性• [Congenital] 先天性• [Familial] 家族性• [Cholestatic] 胆汁淤积性• [Hematogenous] 血源性• [Malignant] 恶性• [Painless] 无痛性（12）意识障碍的表示方法• [Somnolence] 嗜睡• [Confusion] 意识模糊• [Stupor] 昏睡• [Coma] 昏迷• [Del irium] 谵妄• [Syncope (swoon; faint)] 晕厥• [Drowsiness] 倦睡（13）排尿的表示方法• [Enuresis (Bed-wetting)] 遗尿• [Anuria] 无尿• [Emiction interruption] 排尿中断• [Interruption of urinary stream] 尿线中断• [Nocturia] 夜尿• [Oliguria] 少尿• [Polyuria] 多尿• [Pass water (Make wat er; urinate; micturition)] 排尿• [Frequent micturition (Frequency of micturition; fruquent urination; Pollakiuria)] 尿频• [Urgent micturition (Urgency of urination or micturition)] 尿急• [Urodynia (Pain on micturition; painful micturition; alginuresis; mictu rition pain)] 尿痛• [Dysuria (Difficulty in micturition; disturbance of micturition)] 排尿困难• [Small urinary stream] 尿线细小• [Void with a good stream] 排尿通畅• [Guttate emiction (Dribbling following urination;terminal dribbling)] 滴尿• [Bifurcation of urination]尿流分*• [Residual urine] 残余尿• [Extravasation of urine] 尿外渗• [Stress incontinence] 压力性尿失禁• [Overflow incontinence] 溢出性尿失禁• [Paradoxical in continence] 反常性尿失禁3．少见症状• [Weekness( Debility; asthenia; debilitating)] 虚弱（无力）• [Fatigue (Tire; lassitude)] 疲乏• [Discomfort (Indisposition; malaise)] 不适• [Wasting (thin; underweight; emaciation; lean)] 消瘦• [Night sweating] 盗汗• [Sweat (Perspiration)] 出汗• [Cold sweat] 冷汗• [Pruritus (Iching)] 搔痒• [Asthma] 气喘• [Squeezing (Tightness; choking; pressing) sensation of the chest] 胸部紧缩（压榨）感• [Intermittent claudication] 间歇性跛行• [Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis)] 吞咽困难• [Epigastric (Upper abdominal) discomfort] 上腹部不适• [Anorexia (Sitophobia)] 厌食• [Poor appetite (Loss of appetite)] 纳差• [Heart-burn( Pyrosis)] 胃灼热• [Stomachache( Pain in stomach)] 胃部痛• [Periumbilial pain] 脐周痛• [Belching (Eructation)] 嗳气• [Sour regurgitation] 返酸• [Abdominal distention(bloating)] 腹胀• [Pass gas( Break wink)] 肛门排气• [Small(Large) stool] 大便少（多）• [E xpel(Pass) worms] 排虫• [Pain over the liver] 肝区痛• [Lumbago] 腰痛• [Pica(Parorexia; allotriophagy)] 异食癖• [Dysmenorrhea] 痛经• [Menoxenia (Irregular menstruation)] 月经不调• [Polymenorrhea (Epimenorrhea)] 月经过频• [Oligomenorrhea] 月经过少• [Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea)] 经量过多• [Hypomenorrhea (Scantymenstruation)] 经量过少• [Menopause (Menostasia; menostasis)] 绝经• [Amenorrhea (Menoschesis)] 闭经• [Leukorrhagia] 白带过多• [A***uality (lack of libido)] 无性欲• [Hypo***uality] 性欲低下• [H yper***uality] 性欲亢进• [Prospermia (Ejaculatio praecox)] 早泄• [Impotency (impotence)] 阳萎• [Nocturnal emission (Spermatorrhea)] 遗精• [Lack of potency] 无性交能力• [Hair loss] 脱发• [Joint pain (Arthralgia; arthrodynia)] 关节痛• [Polydipsia (Excessive thirst)] 多饮（烦渴）• [Polyphagia (Excessive appetite; hyperorexia; bulimia)] 多食• [Cold (Heat) intolerance] 怕冷（热）• [Dwarfism (Excessive height)] 身材矮小（高大）• [Excessive sweating] 多汗• [Hands tremble] 手抖• [Obesity (Fatty)] 肥胖• [Agitation (Anxiety;nervous irritability)] 焦虑（忧虑）• [Mania] 躁狂• [Hallucination] 幻觉• [Aphasia (Logopathy)] 失语• [Amnesia (Poor memorization;memory deterioration)] 记忆力下降• [Hemianesthesia] 偏身麻木• [Formication] 蚁走感• [Tingling] 麻刺感• [Hyperpathia] 痛觉过敏• [Hypalgesia] 痛觉减退• [Illusion] 错觉• [Hemiplegia] 半身不遂• [Insomnia (Poor sleepness;sleeplessness)] 失眠• [Nightmare] 多梦• [Numbness] 麻木• [Pain in limbs (Acrodynia)] 肢体痛• [Limitation of motion] 活动受限• [Tetany] 手足抽搐• [Discharge of pus] 流脓• [Blurred vision(Hazy vision;blurring of vision; dimness of visi on)]视物模糊• [Burning (Dry) sensation] 烧灼（干燥）感• [Tearing (Dacryorrhea;Lacrimation)] 流泪• [Double vision (Diplopia)] 复视• [Strabismus] 斜视• [Hemianopia] 偏盲• [Tired eyes (Eyestrain)] 眼疲劳• [Foreign body sensation] 异物感• [Lose the sight (Lose of vision)] 失明•[Diminution of vision] 视力减退• [Nictition] 眨眼• [Ophthalmodynia (Eye-ache;ocular pain)] 眼痛• [Photophobia] 畏光• [Spots before the eyes] 眼前黑点• [Deafness(Anacusia)] 耳聋• [Auditory dysesthesia] 听力减退• [Otalgia (Otodynia;pain in the ear ;ear-ache)] 耳痛• [Stuf fy feeling in the ear] 耳闭气• [Tinnitus] 耳鸣• [Outophony] 自声过强• [Nasal obstruction (blockage)] 鼻塞• [Dryness of the nose] 鼻干燥• [Rhinorrhea (Snivel;Nasal discharge)] 流鼻涕• [Sneezing] 打喷嚏• [Snoring] 打鼾• [Hyposmia (Reduction of the sense of smell)] 嗅觉减退• [Anosmia (Complete loss of sense of smell)] 嗅觉丧失• [Dysphonia] 发音困难• [Hoarseness] 声嘶• [Pain on swallowing] 吞咽痛• [Saliva dribblies from the mouth] 流涎• [Troaty voice] 声音沙哑• [Stridor] 喘鸣• [Red and swollen] 红肿• [Scurf] 头皮屑• [Show] 见红• [Amniotic fluid escaped] 破水• [Uterine contraction] 宫缩• [Acalculia] 计算不能• [Apathy] 情感淡漠• [Delusion] 妄想4、时间的表示方法（1）月（Month）• [January,Jan.] 一月• [February,Feb.] 二月• [March,Mar.] 三月• [April,Apr.] 四月• [May] 五月• [June,Jun.] 六月• [July,Jul.] 七月• [August,Aug.] 八月• [September,Sept.] 九月• [October,Oct.] 十月• [November,Nov.] 十一月• [December,Dec.] 十二月（2）周（Week）。