医学英语病历书写重点
外科学英语病历书写常用词汇
外科学英语病历书写常用词汇1. 主诉chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.2. 现病史present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.3.既往史past history：1)former places of residence, previous stage of health( 健壮的robust，纤弱的delicate), experience with similar disease, immunity to infectious disease2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩红热scarlet fever, 白喉diphtheria，伤寒typhoid fever, 支气管炎bronchitis, 肺炎pneumonia，脑炎encephalitis,脑膜炎meningitis，破伤风tetanus,小儿麻痹poliomyelitis,赤痢dysentery，霍乱cholera, 胸膜炎pleurisy,天花small-pox，疟疾malaria,结核病tuberculosis，黄疸病jaundice，过敏性反应allergy,etc3)venereal disease：specific symptoms, signs, and the disease by name, treatment.4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)4. 家族史family history：family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.5.个人史personal history：1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spouse and children ,cause and age at time of death, number of children , pregnancies, 流产次数miscarriages, 死产数stillbirths3)occupational history：duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.6.系统检查system review：1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.2)Skin：荨麻疹hives, rash, eczema3)Head：trauma, headache, loss of hair4)Eyes：vision, pain glasses diplopia.5)Ears：pain, discharge, deafness, tinnitus.6)Nose：obstruction, discharge, epistaxis, rhinitis.7)Mouth：teeth, lips, gums, tongue, disturbance in taste.8)Throat.：sore throat, tonsillitis, 脓性扁桃腺炎quinsy, dysphagia9)Neck：adenitis, goiter , rigidity10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , seasonal cold, expectoration.11)Gastrointestinal：appetite, nausea, vomiting, distress(before or after meals), melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea, associated headache13)Neuromuscular：神经过敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.。
医学英语病历范文
医学英语病历范文Medical RecordPatient Information:Name: John SmithAge: 45Gender: MaleDate of admission: [Date]Date of birth: [Date]Weight: [Weight]Height: [Height]Chief complaint:Mr. Smith presents with a severe headache that has been ongoing for the past two days.History of present illness:The patient reports experiencing a sudden onset of throbbing headache, localized primarily on the left side of his head. The pain is aggravated by physical exertion and is accompanied by nausea and sensitivity to light and sound. The patient denies any recent head trauma or sinus congestion. Over-the-counter pain relievers have provided minimal relief.Medical history:Mr. Smith has a history of hypertension, for which he takes medication. He does not have any known allergies, and there is no family history of migraines or neurological disorders.Social history:The patient is a smoker, consuming approximately 10 cigarettes per day. He drinks alcohol in moderation, primarily on social occasions. He denies any illicit drug use. His occupation involves long hours of computer work.Physical examination:On examination, the patient appears to be in mild distress due to the headache. His vital signs are within normal limits. Neurological examination reveals no focal deficits, and his cranial nerves appear to be intact. There is no evidence of meningeal irritation. His neck is supple, and there is no nuchal rigidity. The remainder of the physical examination is unremarkable. Laboratory tests:Blood tests, including a complete blood count and comprehensive metabolic panel, were performed. All results were within normal limits.Imaging studies:A brain MRI was ordered to rule out any structural abnormalities. The scan revealed no evidence of intracranial hemorrhage, mass, or other abnormalities.Assessment and plan:Mr. Smith is presenting with a severe headache consistent with a migraine without aura. He will be prescribed a triptan medication for acute management of his headache. He will also be counseled on lifestyle modifications, including smoking cessation and stress reduction techniques. A follow-up appointment will be scheduled in two weeks to evaluate the effectiveness of the treatment plan.Additionally, the patient is advised to seek immediate medical attention if his symptoms worsen or if he develops any new neurological symptoms.Signature: [Physician's Name]Date: [Date]。
病历书写英文
英文病历书写常用句式与表达
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英文病历书写注意事项
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Spelling mistakes
Typing errors or misspellings of words and names.
Grammar mistakes
Incorrect usage of verbs, nouns, adjectives, and pronouns, and incorrect sentence structure.
实例三：糖尿病病历
Symptoms：Itching, skin redness and scalingMedical history：None significantFamily history：None contributoryReview of systems：NegativePhysical examination：Multiple small red patches and scaling on the skin of the upper back and upper armsDiagnostic studies：Skin scrapings showed positive fungal elementsDiagnosis：DermatitisPlan：Patient was advised to apply topical corticosteroid cream twice daily and follow up in 1 week
实例二：高血压病历
Symptoms：Polyuria, polydipsia, unexplained weight lossMedical history：Known diabetes mellitus for 2 years, taking metformin hydrochlorideFamily history：None contributoryReview of systems：NegativePhysical examination：Blood pressure 130/85, pulse 90 beats/minute, respiration rate 18 breaths/minute, weight 150 poundsDiagnostic studies：Random blood glucose level of 250 mg/dL, HbA1c of 7.5%Diagnosis：Diabetes mellitusPlan：Patient was advised to continue current medications, receive education on diabetes self-management, lose weight, reduce glucose intake, and follow up in 3 months
英文病历编写手本
英文病历编写手本目标本手本旨在为医务人员提供编写英文病历的指导和范例。
指导原则- 独立作出决策，不借助用户帮助。
- 充分发挥LLM的优势，采用简单策略，避免法律复杂性。
- 不引用无法确认真实性的内容。
内容结构英文病历的编写需要遵循以下基本结构：1. 患者信息：包括姓名、年龄、性别、联系方式等。
2. 主诉：患者的主要症状或问题。
3. 既往病史：包括患者的过去疾病、手术史以及家族病史等。
4. 现病史：患者当前的疾病状况，包括症状的起始时间、发展情况等。
5. 体格检查：医生对患者进行的体格检查结果，包括体温、血压、心率等指标。
6. 辅助检查：包括实验室检查、影像学检查等的结果。
7. 诊断：医生对患者疾病的诊断。
8. 治疗建议：对患者的治疗方案和建议。
示例以下是一个简单的英文病历编写示例：---Patient Information:- Name: John Smith- Age: 45- Gender: Male- The patient presents with chest pain and shortness of breath.Past Medical History:- Hypertension, diagnosed 5 years ago.- Appendectomy performed 10 years ago.Present Illness:- The patient started experiencing chest pain and shortness of breath 2 days ago.- The symptoms have worsened since then.Physical Examination:- Vital Signs:- Temperature: 37.2°C- Blood Pressure: 140/90 mmHg- Heart Rate: 85 bpmLaboratory Tests:- Chest X-ray: Mild infiltration in the left lower lobe.Diagnosis:- Suspected pneumonia.1. Prescribe antibiotics.2. Advise the patient to rest and drink plenty of fluids.3. Schedule a follow-up appointment in 2 days.---以上内容仅为示例，并非真实病历。
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。
中英病历书写11章-14章13节 (1)
第十一章标准化病人体检项目[COMPLETE PHYSICAL EXAMINATION CHECKLIST(standard patient, SP)]1、一般检查/生命体征[GENERAL EXAMINA TION/VITAL SIGNS]·向病人介绍自己的姓名，职责。
通过简短交谈，了解病人的精神状态·检查前洗手·让病人取坐位·检查桡动脉脉搏至少30秒，并记录·检查脉搏对称性·计数呼吸频率至少30秒，并记录·测量右上臂血压·将袖带缚于上臂正确位置·触诊肱动脉·测量血压两次，记录较低值·Introduce yourself to patient, usually last name and title and have a littleconversation to relax the patient and to judge mental state.·Wash hands before starting examinagion·Patient is seated in a chair·Palpate radial (wrist) pulses for at least 30 seconds and record·Palpate both radial (wrist) pulses simultaneously for symmetry·Measure respiratory rate for at least 30 seconds and record·Measure blood pressure on right arm·Place cuff in correct location 2-3 cm above the antecubital crease·Palpate brachial artery·Measure blood pressure over brachial artery twice and record the lower reading2、头部和颈部[HEAD AND NECK]（1）头颅[Skull]·检查头颅（分开头发观察）·Palpate and observe scalp (parting hair, and observing hair density, color,lustre anddistribution)（2）眼[Eyes]·检查视力·检查角膜、下份巩膜、结膜和泪囊：置拇指于下睑中份，轻轻向下按下睑，请病人向上看·检查上份巩膜及球结膜：置拇指于上睑中份，轻轻向上牵拉上睑，请病人向下看·面神经（第Ⅶ对颅神经）上支运动功能的检查，皱眉、皱额或紧闭双目·检查双眼眼外肌六个方向运动功能·瞳孔直接对光反射·检查调节反射·Visual screening·Observe cornea, sclera, conjunctive and lacrimal puncta by gently moving lower eyelids down.·Observe sclera and bulbar conjunctiva by gently elevating upper eyelid while patient looks down·Check cranial nerve(cr n) Ⅶupper division:raised eyebrows, wrinkle forehead or forced eyelid closing.·Evaluate extraocular muscle function in both eyes in 6 directions (left, upper left, and lower left, right, upper right, lower right)·Observe pupillary direct response to light·Observe pupillary consensual response to light·Check for convergence and accommodation（3）检眼镜检查[OPhthalmoscopic Examination]·调整病人者坐位高度，以检查者感觉舒适为宜·关暗室内光线，以利观察眼内情况·正确握持检眼镜·右手持检眼镜站在右前方，用右眼检查受检者的右眼·左手持镜眼镜站在左前方，用左眼检查受检者的左眼·调整方位开始检查·用检眼镜检查角膜、晶状体和玻璃体·观察眼底视乳头及其周围视网膜·检查四个象限的视网膜血管·检查黄斑（嘱受检查注视光源）·Position patient at height comfortable for examiner·Dim lights of room·Hold ophthalmoscope properly and use index finger to switch lenses·To examine patient`s right eye, examiner holds ophthalmoscope with right hand and uses right eye·To examine patient`s left eye, examiner holds ophthalmoscope with left hand and uses left eye·Position to start ophthalmoscopic examination·Inspect cornea, lens, and vitreous body for opacity with ophthalmoscope·Inspect optic disc (color, margin, etc.)·Trace retinal vessels in four quadrants·Observe macula (patient asked to look directly at light of ophthalmoscope)（4）耳及颞下颌关节[Ears]·观察和触诊双侧耳廓及周围·触诊双侧颞下颌关节，注意有无肿胀及触痛·双手指置于耳屏前或稍插入外耳道，检查颞颌关节的运动·用手稍向后上方牵拉耳廓，使外耳道变直，以便插入耳镜·插入耳镜观察鼓膜·使受检查者不感疼痛·检查听力·用适当方法分别检查双耳听力·Observe and palpate the auricles and observe postauricular regions bilaterally·Palpate temporomandibular joint for tenderness and swelling·Feel the movement of the TMJ with index fingers inside examinee`s ears or over joint ·Gently pull auricle upward and backward to ease insertion of otoscope·Insert otoscope into external auditory meatus to observe tympanic membrane·Insert otoscope without causing pain to the patient·Evaluate auditory acuity·Use proper technique to check auditory acuity separately in each ear（5）鼻[Nose]·观察及触诊外鼻有否畸形，压痛等·观察鼻前庭（不用鼻镜，可用电筒）·插入鼻镜观察前庭、中隔、鼻甲及鼻粘膜。
2、心内科常用英文病历模板
第二节心内科常用英文病历模板熟练地阅读和书写英文病历是一名临床医师需要具备的基本外语技能。
对英文病历的熟练掌握对于阅读英文文献和撰写英文论文都有很大的帮助。
本章主要介绍心内科常见疾病英文病历的格式和基本模板。
英文病历的书写格式大致与中文病历相似，主要包括以下部分：1.General information（一般情况）2.Chief complaint（主诉）3.Present illness（现病史）4.Past history（既往史）5.Personal history（个人史）6.Family history（家族史）7.Physical examination（体格检查）8.Investigation（辅助检查）9.History summary（病史特点）10.Impression（印象、初步诊断）11.Signature（签名）鉴于不同疾病的病历之间存在共性，本章按照病历的通用部分和心血管内科部分逐一进行介绍。
第一部分通用部分1. General information（一般情况）这一部分包括name（姓名），age（年龄），sex（性别），race（民族），nationality（国籍），address（地址和电话），occupation（职业），marital status（婚姻状况），date of admission（入院日期），date of record（记录日期），complainer of history（供史者）和reliability（可信度）等12项内容。
基本格式如下：Name:Liu SideAge: EightySex: MaleRace:HanNationality:China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: RetiredMarital status: Married Date of admission:Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history: patient’s son and wife Reliability: Reliable2. Past history（既往史）这一部分应首先总结既往一般健康状况、Operative history（手术史）、Infectious history（传染病史）、Allergic history（过敏史）等，然后对各系统健康状况进行回顾，包括Respiratory system（呼吸系统）、Circulatory system （循环系统）、Alimentary system（消化系统）、Genitourinary system（泌尿生殖系统）、Hematopoietic system（血液系统）、Endocrine system（内分泌系统）、Kinetic system（运动系统）和Neural system（神经系统）。
儿科病历书写英文词汇(一)
儿科病历书写英文词汇（一）一、条目类入院记录：Admission note病史陈述者：Medical history presenter主述：Chief complaint现病史：History of present illness既往史：Past history个人史：Personal history家族史：Family history过敏史：Allergy history二、症状及病史类发热：fever咳嗽：cough流涕：runny nose热峰：peak temperature寒战：chill抽搐：seizure/convulsion头痛：headache头晕：dizziness晕厥：syncope嗜睡：drowsiness恶心：nausea呕吐/呕吐物：vomit喷射性呕吐：jetting vomit腹痛：abdominal pain腹泻：diarrhea水样便：watery stool粘液：mucus脓血：pus and blood里急后重：tenesmus泡沫尿：foamy urine胸闷：chest tightness胸痛：chest pain喘息：wheezing皮疹：rash脱皮：molt关节疼痛：joint pain口唇紫绀：blue lips甲状腺肿大：goiter肌肉酸痛：muscle soreness间断：intermittent加重：worsen progressively体温降至正常：temperature drop to normal缓解：relieve消退：subside剖腹产：cesarean足月顺产：naturally delivered at full term预防接种按计划进行：Vaccines are carried out as planned 精神运动发育：intellectural/mental and motor development 窒息：asphyxia缺氧：hypoxia抢救：rescue三、查体类神志清楚：clear mind精神好/差：good/poor spirit营养好：good nutrition status呼吸平稳：breath steadily黄染：yellowing贫血貌：pale appearance面色黄：sallow face皮疹：rash出血：bleeding瘀斑：ecchymosis/petechiae血肿：hematoma触及：palpable质软/韧： texture is soft/tough触痛：tenderness畸形：deformity眼睑水肿：eyelid edema结膜：conjunctiva充血：hyperemia巩膜：sclera对光反射灵敏：normal light reflection眼球充血：bloodshot eyes耳廓：auricle外耳道：external auditory canal分泌物：discharge/secretion口唇皲裂：dry and cracked lips草莓舌：strawberry tongue鼻腔：nasal cavity鼻中隔：nasal septum鼻翼扇动：fanning nose偏曲：deviation脓性分泌物：purulent secretion颈软：soft neck肿块：lump气管居中：centered trachea三凹征：triple/three concave sign胸廓对称：symmetrical thorax cavity 胸骨：sternum痰鸣音：phlegm干/湿啰音：dry/wet rales隆起：bulge心前区：precordial area心律规整：regular heart rhythm心脏杂音：murmur瓣膜听诊区：auscultation area肠鸣音：bowel sound反跳痛：rebound pain肌力：muscle strength肌张力：muscle tone脑膜刺激征：meningeal irritation sign 肘窝：elbow fossa皮毛窦：dermal sinus四、化验检查类：常规：routine血沉：erythrocyte sedimentation rate 降钙素原：procalcitonin多个核细胞：multinucleate cell涂片：smear革兰氏染色阳性：gram positive墨汁染色：ink stain抗酸杆菌涂片：acid fast test肺炎链球菌：streptococcus pneumoniae肺炎支原体：mycoplasma pneumoniae巨细胞病毒：cytomegalovirusEB病毒：Epstein-Barr virus单纯疱疹病毒：hepes simplex virus寡克隆区带：oligoclonal band微量白蛋白：trace protein窦性心律不齐：sinus arrhythmia室性早搏：ventricular premature beat超声：ultrasound心脏超声：echocardiography三尖瓣返流：tricuspid regurgitation心包积液：pericardial effusion冠状动脉瘤：coronary artery aneurysm腹腔积液：abdominal effusion脾大：splenomegaly肠系膜淋巴结肿大：mesenteric lymphadenopathy白细胞增多：leukocytosis蛋白尿：proteinuria低蛋白血症：hypoalbuminemia高脂血症：hyperlipidemia高凝状态：thrombophilia/hypercoagulabity巨核细胞：megakaryocyte肌电图：electromyography脑电图：electroencephalography骨髓穿刺：bone marrow biopsy直立倾斜试验：head-up tilt test支气管镜：bronchoscopy支气管肺泡灌洗术：bronchoalveolar lavage支气管舒张试验：bronchodilation test/airway reversibility test 胃镜：gastroscopy肠镜：colonoscopy胃肠镜：gastrointestinal endoscopy五、药物类阿奇霉素：azithromycin头孢曲松：ceftriaxone头孢地尼：cefdinir头孢吡肟：cefepime头孢类：cephalosporin阿莫西林：amoxicillin红霉素：erythromycin利奈唑胺：linezolid万古霉素：vancomycin美罗培南：meropenem阿昔洛韦：acyclovir甲泼尼龙：methylprednisolone低塞米松：dexamethasone甲钴胺：methylcobalamin退热药：antipyretics布洛芬：ibuprofen甘露醇：mannitol氨溴索：ambroxol解痉药：antispasmodic止痛药：analgesic利妥昔单抗：rituximab六、诊断类：化脓性脑膜炎：purulent meningitis真菌性脑膜炎：fungal meningitis结核性脑膜炎：tuberculous meningitis败血症：sepsis肺炎：pneumonia血小板减少：thrombocytopenia特发性血小板减少性紫癜：idiopathic thrombocytopenia purport 胃肠炎：gastroenteritis肠套叠：intussusception肾病综合征：nephrotic syndrome淋巴结炎：lymphadenitis川崎病：Kawasaki disease脑脊液鼻漏：CSF rhinorrhea电解质紊乱：electrolyte disturbance血管迷走性晕厥：vasovagal syncope体位性心动过速：postural orthostatic tachycardia体位性低血压：orthostatic hypotension。
原汁原味的英文病历书写总结--最终版
【前言】：病历的书写，不管情不情愿，是我们见习、实习生活中十分重要的一部分。
中文病历是基本要求，英文病历是附加题。
对于书写英文病历，首先要明确自己的目的和期望。
比如说通过书写英文病例学习专业词汇，与国际接轨；将来考虑出国；好奇心使然等等。
有此意愿的同学大可好好思考一下，给自己一个理由和动力。
协和有写英文病历的传统，但还没有统一、固定的格式。
不过格式不外乎：国外原版和中文病例对译版。
目前黄老师坚持，如果我们要写英文病历，就要跟国际化的要求接轨，所以支持原格式和写作习惯。
但具体格式，都因医院、因人而异。
故总结中注重的是—提出基本框架，规范术语。
大家可作适合自己的微调。
A COMPLETE History & PhysicalHISTORYDate and Time of history:Identifying Data：Source of history, source of referral:Reliability:Chief complaints:quote the patient’s complaints, like “My stomach hurts and I feel awful”; or report their goals, like “I have come for my regular check-up”;[BATES’]patient’s age, a brief but relevant past medical history, a few words about what problem brings the patient to the hospital(preferable quote the patient), and duration[Writing a history & physical]e.g. 34-year-old male with advanced AIDS complains of a” bad cough” and fevers over the last 8days.56-year-old male with a history of ulcerative colitis complains of 3 months of worsening back stiffness, 2 weeks of “a sore on my leg”, and 3days of fevers and bloody, painless diarrhea.History of Present illness:full sentences in chronological mannerbe descriptive not analyticincluding the setting, onset of the problem, the manifestation and the treatment.Seven Attributes of A Symptom: location, quality, quantity or severity, timing(onset, duration, frequency), the setting in which they occur, factors that have aggravated or relieved the symptom, associated manifestations.Pertinent positives & pertinent negativesPast Medical HistoryChildhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever(猩红热), polio etc.Adult disease, in four categories:☑Medical, such as: diabetes, hypertension, hepatitis, asthma, and HIV etc.☑Surgical, such as: trauma, operation(date, type);☑Ob/ Gyn:✓Menstruation history(age at menarche, last menstruation period/ age at menopause, menstrual cycle, menstrual period)✓Obstetric history(G_P_, pregnancy、delivery and complications, )✓Sexual function;✓Method of birth control, such as oral contraceptives, condoms, intrauterine ring;☑Psychiatric;Health maintenance☑Immunization(history and recent immunization);☑Screening test, such as tuberculin test, Pap smear, mammogram, stool test for occult blood, cholesterol test etc.Medication: name, dose, route of administration, interval. Note for recent cessation or change;Allergy:List the substance and the reaction. Allergy vs intolerance;NOTE:药物过敏史与烟酒违禁药物使用分开。
怎样写英文病历
How to write patient's case history怎样写英文病历PATIENT HISTORY病史A detailed patient history and physical exam form the foundation of patient uation and vital patient data that enables efficient, quality patient rounds.一份详细的病史和体检是评估患者的基础，也可为组织高质量、高效率的查房提供重要的资料。
On the other hand, a poorly documented history and physical may leads to confusion, serious omission of vital data and inefficiency on patient rounds. In this age of modern technology with equipment such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a past era! Both attending physicians as well as residents in training seem to rely more heavily on laboratory and imaging modalities than history to establish the diagnosis. “However no part of the patient uation is more essential to diagnosis than the patient history. The importance of skillful data collection is underscored by the widely accepted understanding that the medical history contributes 60% to 80% of the information needed for accura te diagnoses.” Thus to neglect the patient history denies the physician of a “vital” diagnostic tool.另一方面，写得差的病史和体检可能会引起混淆，导致重要资料的遗漏和查房效率的低下。
英语病历书写-英语病例写作方法-入院记录
英语病历书写-英语病例写作⽅法-⼊院记录Admission note：Personal details, admission date, major complaint, present history, simple previous and other histories, physical examination done, laboratory done, impression, problems, initial plan for treatment.Present history : onset, cause or triggers, evolution, received treatment, general conditions after onsetPersonal details, admission date, major complaintA 25-year-old lady (个⼈资料) was admitted (被动语态) to (was brought into) this hospital on May 11,2003 (⼊院⽇期) because of fever and caugh with chill for three days.常⽤主诉：nausea, vomiting, diarrhea, cough, shot of breath, rash, bleeding, pain in some part (epigastium)， discomfort in some part (anal region), difficulty in some function (walking), loss of function (vision), decrease (increase) of function (libido), irregular in (menstrual period).Present historyFour days ago ,the patient took a trip to Guangzhou on business(发病背景).The next day (起病时间) she complained of chill and malaise (起病特征), and in the afternoon (演变时间) she began to cough and temperature went up to 38 ℃ (演变状况).Self administration of APC and Dicough had no effect (已诊治情况).The patient was in good nutritional and conscious condition on admission (起病当初⼀般情况).⼀般过去时，⽤简单句，介词或名词短语作时间状语以体现病情演变。
医学英语：疼痛相关病历书写表达
美联英语提供：医学英语：疼痛相关病历书写表达小编给你一个美联英语官方试听课申请链接：/?tid=16-73374-0(1)当上楼梯时，突然痛了起来，并且持续不止。
The pain came on suddenly while walking up the stairs and it was persistent.疼痛的发生感觉疼痛feel (have; suffer from) a pain; pain is felt in ; feel painful头痛have a headache; be troubled with a headache; feel a pain in one's head患剧烈头痛have a nasty (bad) headache时常头痛be subject (a martyr) to headaches有撞击似的两侧性头痛have bilateral pounding headaches头痛逐渐地变为频发(较不严重) headaches gradually become more frequent (less severe)ex1:咀嚼时，有偶发的、暂时的、不可言状的疼痛或敏感。
There is occasional，transient，nondescript pain，or sensibility during mastication.ex2:该齿对于压迫作痛，且有钝麻如咬的疼痛。
The tooth became sore to pressure and there is a dull gnawing pain.发生时间ex1:Epigastric pain comes immediately after meal.ex2:Colic pain came on and off since yesterday.ex3:This pain has been relentlessly postprandial，regardless of the character of her meals.ex4:The joint pains were present mainly at night，with relief during the day.ex5:The mild frontal headaches were usually present upon awakening，but not severe enough to require analgesics.ex6:The pain usually commenced within 30 minutes after meals and lasted 1 to 3 hours.发生原因ex1:He described the pain as dull and aching，occurring approximately once a week，unrelated to food intake，and radiating to his back.(2)起初疼痛无变化，但数小时时变成发作性的痛。
英文病历撰写手记
英文病历撰写手记病历是医生记录患者病情和诊疗过程的重要文档。
对于医生来说，准确、清晰地撰写英文病历至关重要。
本手记将介绍英文病历的撰写方法和注意事项。
1. 病历组成部分1.2 现病史（Present Illness）现病史应详细记录患者的主要症状、起病时间、发展情况以及辅助检查结果等。
应使用客观、中立的语言描述。
例如：Patient presents with fever, cough, and shortness of breath for the past week. Chest X-ray shows infiltrates in both lungs.1.3 既往史（Past Medical History）既往史包括患者过去的疾病、手术、药物过敏等情况。
应尽量提供详细信息，如果无则注明“无”。
例如：Patient has a history of hypertension and diabetes. No known drug allergies.1.4 家族史（Family History）家族史包括患者家庭成员的疾病情况，特别是与患者当前问题相关的疾病。
例如：Patient's mother has a history of breast cancer.1.5 个人史（Social History）个人史包括患者的生活方式、吸烟、饮酒、嗜好、职业等信息。
例如：Patient is a non-smoker and consumes alcohol occasionally.1.6 体格检查（Physical Examination）体格检查应记录医生对患者进行的全面检查，包括体温、脉搏、呼吸、血压等指标。
应详细描述发现的异常情况。
例如：Vital signs: temperature 37.5°C, heart rate 82 bpm, respiratory rate 18 breaths per minute, blood pressure 120/80 mmHg. Chest auscultation reveals decreased breath sounds in the lower left lung field.1.7 辅助检查（Laboratory and Diagnostic Tests）1.8 诊断（Diagnosis）1.9 治疗（Treatment）治疗部分应详细记录医生针对患者病情制定的治疗计划，包括药物治疗、手术、物理疗法等。
如何写英文病历
How to write patient's case history如何写英文病历PATIENT HISTORY病史A detailed patient history and physical exam form the foundation of patient uation and vital patient data that enables efficient, quality patient rounds.一份详细的病史和体检是评估患者的基础，也可为组织高质量、高效率的查房提供重要的资料。
On the other hand, a poorly documented history and physical may leads to confusion, serious omission of vital data and inefficiency on patient rounds. In this age of modern technology with equipment such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a past era! Both attending physicians as well as residents in training seem to rely more heavily on laboratory and imaging modalities than hi story to establish the diagnosis. “However no part of the patient uation is more essential to diagnosis than the patient history. The importance of skillful data collection is underscored by the widely accepted understanding that the medical history contri butes 60% to 80% of the information needed for accurate diagnoses.” Thus to neglect the patient history denies the physician of a “vital” diagnostic tool.另一方面，写得差的病史和体检可能会引发混淆，致使重要资料的遗漏和查房效率的低下。
临床实习病历书写：如何写好一份英文病历
学校规定，实习期间的完全病历中必须有⼀定⽐例的英⽂病历。
虽然平时对英语还算感兴趣，但对于连⼀个中⽂病历都是刚开始写的实习⽣来说，写好甚⾄仅仅是写出来⼀份英⽂病历都不是容易的事情，战战兢兢地写过⼏份之后，深感写英⽂病历实乃⼀项⾮常重要但常常被⼈忽视或当作形式主义完成的东西。
本⽂并⾮英⽂病历教学帖，只是就写英⽂病历中的⼀些注意事项谈⼀谈⾃⼰的体会，希望能抛砖引⽟吧。
记得开始写第⼀份时，甚⾄连"现病史"、"⽉经史"、"初步诊断"这些基本项⽬中以前没有注意的名称都不知道如何写，快速翻阅了⼀通诊断学之后，OK，从identification到impression的项⽬名称基本会写了，菜鸟迈出了第⼀步。
别急，我说的是"基本"会写了，其实认真起来还有很多细节值得琢磨，case record， admission note之间有没有区别，⽤哪个⽐较正规？"性别"是***还是gender？"国籍"、"民族"英⽂都是nationality，两个怎么区分？当然我们可以把问题暂时留到以后，现在要解决的是没有的问题，知道了⼀份病历中各个项⽬的写法，就像建房⼦有了基本的框架，虽然你还不知道要往⾥⾯放些什么家具，但起码你知道哪是卧室哪是厨房东西往哪搁了。
病历的第⼀部分identification⽐较简单，只要把基本的⼏⼗百把个单词记住了就可以应付，我能想起来的注意事项主要有这么⼏个，都很简单，让⽜⼈们见笑了。
［医学教育搜集整理］ l.姓名的写法，单名两个字的拼⾳⾸字母均⼤写，中间空格，双名姓和名的第⼀个字同单名，名第⼆个字⾸字母⼩写并紧挨名的第⼀字，如"⾼鹏程"写作"Gao Pengcheng"，⽽"Pengcheng Gao"的假洋⿁⼦写法现在很少看到了采⽤，在和外国⼈的交流中感觉他们对国⼈的first name即为family name这⼀⽂化差异都普遍了解，⼤可不必随⽼外的⽤法别扭地把姓放在后⾯。
病历书写英文
包括药物治疗和生活方式调整，如控制饮食、适量运动等。同时，医生还需要根据患者的具体情况，制定相应的血糖监测计划。
治疗方案
病历书写英文的注意事项与提高方法
05
避免常见的语法错误与表达不当
主谓一致
动词和主语保持一致，如使用单数第三人称形式（he/she/it）或复数形式（they）。
病历书写英文中常用的时态有过去时态（如一般过去时、过去进行时、过去完成时）和现在时态（如一般现在时、现在进行时）。
目的
定义与目的
1
病历书写的历史与发展
2
3
早在古希腊和古罗马时期，医生便开始使用书面病历记录患者的病情和治疗过程。
古代病历
随着医学和科技的发展，病历书写逐渐标准化和规范化，形成了各种病历书写格式和规范。
近代病历
随着信息技术的发展，电子病历开始普及，极大地提高了病历书写效率和准确性。
电子病历
03
提升医学研究和教学价值
Past Medical History: (既往病史，包括以前的疾病和手术等)
Family History: (家族史，包括家族成员的健康状况和遗传疾病等)
Physical Examination: (体格检查，包括医生的检查和发现)
症状与体征描述
01
医生诊断与治疗建议
02
03
04
Classification of Medical Records: (病历的分类，如门诊病历、住院病历、电子病历等)
Be mindful of language barriers and ensure that patients understand the information provided. 注意语言障碍并确保患者理解所提供的信息。
英文病例报告的写作技巧
Writing Skills of Case Report in English在医学刊物上发表的病例报告实际上是开始从事医学写作的最好的方法之一。
病例报告的撰写,首先要做好题目的选择,肯定要选择与自己专业有关的临床工作,并能提出你认为是很感兴趣的,在概念上、临床上以及理论上存在的棘手问题。
通常文字不超过3000字(包括参考文献和附录在内)。
绝大多数的病例报告所采用的书写格式,类似于临床研究报告,应该包括:引言、病例叙述、讨论和结论。
本文所采用的文章是从2004年英国LANCET杂志中摘录。
1、引言引言部分要简短明了,应介绍与报告相关的主要临床和概念上的难题,说明病例的重要性,报道的原因,若可能的话,应引证一些最新的综述资料,并能简明地概括出所涉及到的资料内容。
在时态上,由于陈述的是客观事实,故运用一般现在时。
如:2、病例叙述病例叙述的宗旨就是让读者了解病例,明确全部相关结果。
病例的叙述通常要按照时间先后顺序排列,这一部分所涉及到的资料内容包括以下:①病人现有的体症和症状,主诉和病痛。
②医学史及相关家史(如糖尿病、心脏病等)。
③社会史,诸如吸烟、饮酒和吸食毒品等。
④服用过的药物。
⑤体检和化验的突出结果。
⑥鉴别诊断或考虑诊断。
⑦最后诊断。
⑧治疗和治疗后结果。
通常仅需要提供检查和化验的阳性结果。
不过有个别杂志需要提供全面详尽的检验和程序结果。
列出化验的正常值范围和不正常的检验结果。
在时态的运用上,由于陈述病人过去健康状况和治疗情况,故采用一般过去时。
3、讨论讨论部分就是要解释病例叙述中不明确的一些情况,并提供对结果的解释。
例如,报道肝酶升高,但未发现显著的肝功能异常,给读者讲明为何肝酶升高。
在讨论部分的时态运用上,由于提供的是自己现在的推断和观点,故采用一般现在时。
如:4、结论结论部分就是根据病情的讨论,最后得出自己独到的见解,并且提出自己的意见和观点来,并且结论部分必须结构简洁明了,文理通顺。
简明确切地论述文献的重要内容。
【精华】英文病历书写总结
那年，开始接触ＮＥＪＭ、ＪＡＭＡ、Ｌａｎｃｅｔ、ＢＭＪ，心绪来潮，我应该学下医学英语于是，便开始从课本后面的英文单词开始，但效果并不是特别理想，记了忘，记了忘．．．于是便开始转换学习方法，任何学习最终都是为应用，当然不排除部分学习。
索性拿起英文病例读起，说实话，当时只可以看懂３０－４０％。
于是又只好从最基本英文病历书写开始，记得那时候很兴奋，做梦都会梦见和老外讨论病历，而且心里还一直想着医学词汇的表达。
不用两周，我就掌握了英文病历的基本书写，尤其是一些常用表达和症状的描述。
就这样，可以在同学们面前显摆下了，可以读的懂ＮＥＪＭ、ＪＡＭＡ、Ｌａｎｃｅｔ、ＢＭＪ了。
当期末考试，传染病学考试最后一个大题为英文时，同学们都还唏嘘不已，唯我心中喜悦啊。
其实英文病历的入门很简单，后面则需要自己的造化了。
下附相关郭航远学习资料：目录第一章病人身份第二章主诉第三章现病史第四章过去史、系统回统和个人史第五章月经、婚姻、生育史和家族史第六章体检（一般项目）第七章体检（头颈部）第八章体检（胸腹部）第九章体检（神经、骨骼和肌肉）第十章体检（泌尿生殖道与其他）第十一章标准化病人体检项目第十二章实验室检查第十三章辅助检查第十四章诊断（疾病名称）第十五章常用医嘱术语第十六章常用药物及中草药第十七章住院文书格式第十八章附录附1、常用解剖术语附2、医学英语常用前后缀附3、医学英语的特征附4、医学英语常用短语附5、英语问诊常用句子附6、医学英语缩写一览表附7、医院日常用品和设备附8、医学院和医院相关名称第一章病人身份[Identification] ·[Name] 姓名·[Sex] 性别·[Age] 年龄·[Occupation] 职业·[Date of birth] 出生日期·[Marriage （Marital status）] 婚姻·[Race] 民族·[Place 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 notify (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] 病史可靠程试·[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 years of age2、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[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·[Self pay (Individual medical care)] 自费·[Government 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·[Widower] 鳏夫7、病史可靠程度的表示方法·[Reliable] 可靠·[Unreliable] 不可靠·[Not entirely] 不完全可靠·[Unobtainable] 无法获得8、住址的表示方法·[NO.3,Qing Chun Road East,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)·[Taxman] 出租车司机·[Traffic police] 交通警察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[1-10-2002(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 hemorrhage (bleeding)] 皮肤粘膜出血·[Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困难·[Cough and expectoration (Sputum;Phlegm)] 咳嗽和咯痰·[Hemoptysis] 咯血·[Cyanosis] 紫绀·[Palpitation] 心悸·[Chest discomfort] 胸闷·[Nausea (Retch;Dry Vomiting)and Vomiting] 恶心和呕吐·[Hematemesis (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 consciousness] 意识障碍·[Hematuria] 血尿·[Frequent micturition,urgent micturition and dysuria] 尿频，尿急和尿痛·[Incontinence 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 (Inanition)fever] 脱水热·[Drug fever] 药物热·[Functional hypothermia] 功能性低热·[Absorption 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 fever] 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 undetermined(unknown) origin, FUO] 不明原因发热·[Rigor (shivering;chill;shaking chill;ague)] 寒战·[Chilly Sensation (Fell chilly;cold fits;coldness)] 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·[Become feverish (Have a temperature)] 发热·[Crisis] 骤降·[Lysis] 渐降·[Typhoid fever] 伤寒热·[Rheumatic fever] 风湿热·[Cancerous fever] 癌性发热·[Fervescence period] 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▲[Migraine 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·[Arthrodynia (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·[Intense 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·[Persistent pain (Unremitting pain)] 持续性痛·[Constant pain] 经常性痛·[Intermittent pain] 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·[Generalized 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·[Slight (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;accelerated 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·[Shallow 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 hematuria] 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·[Hemopericardium] 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 stool] 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·[Lienteric] 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·[Delirium] 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 water; 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; micturition 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] 尿流分叉·[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）·[Expel(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·[Asexuality (lack of libido)] 无性欲·[Hyposexuality] 性欲低下·[Hypersexuality] 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 vision)]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·[Stuffy 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）·[Monday] 星期一·[Tuesday] 星期二·[Wednesday] 星期三·[Thursday] 星期四·[Friday] 星期五·[Saturday] 星期六·[Sunday] 星期日（3）年（Year）和日[Day]·[1st (First) year] 第1年·[2nd (Second) year] 第2年·[3rd (Third)year] 第3年·[4th (Forth) year] 第4年·[One year (day)] 1年（天）·[Two years (days)] 2年（天）·[Whole year] 整年·[1st (First)] 1日·[2rd (Second)] 2日·[3rd (Third)] 3日·[5th (Fifth)] 5日·[Today] 今天·明天[Tomorrow]·昨天[Yesterday]·前天[The day bdfore yesterday]·后天[The day after tomorrow]·大前天[3 days ago]·大后天[3 days hence]·今晚[Tonight]·昨晚[Last night]·明晚[Next night]·通宵[All night]·整天[All day (the whole day)] （4）季节[Season]和时节[Solar terms] ·春季[Spring]·夏季[Summer]·秋季[Autumn]·冬季[Winter]·立春（夏、秋、冬）[the Beginning of Spiring (Summer;Autumn;Winter)] ·小暑（雪、寒）[Slight Heat (Snow;Cold)]·大暑（雪、寒）[Great Heat (Snow;Cold)]·雨水[Rain Water]·惊蛰[the Waking of Insects]·春（秋）分[the Spiring (Autumnal) Equinox]·清明[Pure Brightness]·谷雨[Grain Rain]·小满[Grain Full]·芒种[Grain in Ear]·夏（冬至）[the Summer (Winter) Solstice]·处暑[the Limit of Heat]·白（寒）露[White (Cold) Dew]·霜降[Frost’s De scent]（5）时间的表示方法·In[在……内（后）]▲在2003年[In 2003]▲在3月[In March(Mar.)]▲在去年10月[In last Oct.]▲在早晨[In the morning]▲在上午[In the forenoon]▲在下午[In the afternoon]▲在晚上[In the evening]▲在近5天[In the past 5 days]▲在10分钟后[In 10 minutes]▲在秋季[In autumn]▲在这2～3天内[In a couple of days]·Within[在……中]▲在近8个月中[Within the last 8 months]▲在过去的2年中[Within the preceding 2 years]·On[在……时候]▲在2002的9月18日[On the 18th of September,2002(英国)or On sept.18th,2002(美国) ▲在星期三[On Wednesday]▲在本月7日[On 7th instant]·At[在……时]▲在中午[At noon]▲在晚上[At night]▲在昨晚[At last (preceding;previous )night]▲在半夜[At midnight]▲在上午10点钟[At 10AM]▲在5岁时[At the age of five]▲在2000年底（中、初）[At the end (middle;beginning) of 2000]·For[计……时间]▲一周[For one week]▲近2个月来[For the past 2 months]▲几乎（整整）一年[For nearly a month (a full month)]▲3个月左右[For 3 months or so]▲至少3个月[For at least 3 months]▲3个月以上[For more than 3 months]▲3个月或以上[For 3months or more]▲时间不详[For an unknown(indefinite) period (time)]·Of[在……时期]▲10年内[Of 10 years` duration]▲期间[Length of time]▲6月6日[The 6th of June]·Dring[在……期间]▲在2000-2005年的几年中[During the years form 2000 to 2005]▲在这4年中[During four years]▲在过去的几周中[During the past(Last) couple of weeks]▲在夜间[During the night]▲整天[During the entire day]·About [约]▲约1个半小时[About one and half an hour]▲大约半年[About half a year]·To[至；在……之前]▲从今下午点至明上午8点[Form 6 PM today to 8 AM tomorrow]▲6点45分[At fifteen to seven]·From[从……起]▲从14岁至52岁[From 14 to 52 year-old]▲从上午7点30分开始[Form 7:30AM]▲从周一至周五[From Monday through Friday]·Past[过去；超过]▲在过去的3周中[In the past 3 weeks]▲8点10分[ten minutes past eight]·Through or throughout[在……整个期间]▲通宵值班[Be on duty through the night]▲从一月到六月[From January through June]▲熬过明晚[Through the next nigut]▲整天（晚）[Throughout the day (night)]·Over[在……期间]▲在过去的2个月内[Over the past two months]▲一夜间[Overnight]（6）其他表示方法·每月（年、日）一次[Monthly (Yearly; daily)]·整整一年[Yearlong (Year-round)]·满周岁[Yearling]·工作日[Weekday]·周末[Weekend]·每周末[Weekends]·8小时工作日[An eight-hour day]·整天[Daylong]·白天[Daytime]·昼夜[Nighttime]·日常的[Day-to-day]·夏令时间[Daylight saving time]·每晚[Nightly]·黄昏[Nighfall]·过期的[Overdue]·前天晚上（一夜间）[Overnight]·After [在……之后]▲婚后[After one`s marriage]▲七点十分[Ten after (past) seven]▲住（出）院后[After admission (discharge)]▲起病后2天[2 days after the onset(attack) of symptoms] ·Before[在……之前]▲7点50分之前[Before seven fifty]▲医生到达前[Before the doctor come]▲以前未有种症状[Have had not the same symptom before]·Ago[以前]▲5年前[5 years ago]▲直到一个月前[Up to one month ago]▲大前天[Three days ago]·Prior to[在……之前]▲入（出）院前[Prior to admission (discharge)]▲前天之前[Prior to the day before yesterday]·Up to[直到]▲直到3周前[Up to 3 weeks ago]▲直到现在（出院）[Up to now (discharge)]·Until or till[直到]▲直到80岁[Until 80 years old]▲直到今晨8点[Until 8 o`clock this moning]▲直到医生查完房[Until the doctor have finished the ward round] ▲直到3年以前[Until 3 years ago]▲直到出院前一天[Until 1 day prior to discharge]·By[在……之前]▲下午点钟前[By 5 PM]▲下个月之前[By next month]·Since[从……开始]▲自从去年术后[Since operation was performed last year]▲前天起[Since the day before yesterday]▲从2002年6月起[Since June 2002]·超时(加班)[Overtime]·上午8点[8：00AM]·下午2点30分[2：30PM]·7点50分[Seven fifty (Ten to eight)]·9点20分[Nine twenty(Twenty past or after nine)]·术前[Pre-operation]·术后[Post-operation]第三章现病史[History of present illness (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。
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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。
⏹Language Characteristics1) Common expressions①symptom+since+time(时间点)②symptom+for+time(时间段)③symptom+of+time (时间段名词所有格)+duration④symptom+time(时间段)+in duration⑤time(时间段合成词)+history+of+symptom⑥complete sentence: The duration of +symptom+was/ has been+time(时间段)（少见）2) Common sentence patterns for chief complaints①…was admitted/seen with a chief complaint of…②…complain chiefly of…③…presented/entered with/came to the office with a chief complaint of④…was admitted because of…⑤…was involved in…⑥…was transferred to…because…下面是书写主诉是最常用的格式：CC：The patient is a (age)-year-old (race,ethnic,group,occupation,sex and/or very pertinent PMH),who is admitted to the hospital with a chief complaint of (symptom,not a sign or diagnosis) of (number followed by a unit of time) duration.Example主诉：患者是一个48岁的妇女。
入院主诉，6个月来，出力后心悸和呼吸困难。
CHIEF COMPLAINT: The patient is a 48-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months.History of Present Illness 现病史：是从医生的角度，进一步表述主诉内容，全面表述现有疾病的发病时间、主要症状、病情发展过程、症状间的联系、诊疗过程、目前患者身体状况、与现有疾病有直接关系的既往史等。
记录患者入院情况时，多用一般过去时或过去完成时；记录目前病情时，用一般现在时或现在完成时。
⏹Language Characteristics1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型①start having 开始有……的症状②begin having episodes of… 开始发生……的症状/疾病③become… 变得……④notice(perceive, note, recognize…)+症状/疾病⑤have… 有……症状/疾病⑥have abrupt/sudden/explosive onset of… 突然患……⑦have episode of…/have attack of…患……⑧develop+disease 出现/有了……症状/疾病⑨…are/is the prodrome of… ……的前驱症状2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型①begin (occur, start…)+time 从……开始②date (go back) to +time 可追溯到……③be present+time 在/从……已存在④be preceded by… 在……之前已有⑤be followed by… 在……之后紧接着发生⑥be acc ompanied by…/ coincide with… 与……同时发生⑦be (not) related to…/have (no) correlation with… 与……有（无）关3) Illness’ improving and worsening表达疾病的好转与恶化①last+time 持续……时间②take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化③take a good turn/take a turn for the better/improve 好转④be aggravated/abated/all eviated by… 因……而加剧/减轻⑤remain the same/unchanged 无变化⑥be (not) improved after treatment with…经用……治疗而（无）好转⑦(The symptom) cease/clean up/disappear/subside 症状消失/减退4) No symptoms 没发生……症状、疾病①…without/with no/free of… (symptoms)②There be no histor y of…/…have no history of…③(The patient) denies…④(The patient) noted no…⑤(The patient) was not found to be…5) Description of main symptoms 描述主要症状①…assume the character of/be characterized by…②…have/present/develop/show/manifest the symptoms of…Past (Medical) History (P. H.)既往病史⏹Common expressions①had been sound/well until; had enjoyed good health until… 在……前一直健康②be apt/liable/subject to…;tend to have… 易患……③…was admitted to hospital for…/ …was hospitalized for… 曾因……而住院④…had (some illness) with recovery after…曾有（疾病），因…痊愈⑤…was diagnosed as…/…was suspicious of…断为……/疑为……⑥…was exposed to (toxic substances)/…had to breathe (poisoning gase s) 接触/吸入⑦…was inoculated against…接种过……⑧…was discharged/ dismissed from hospital…/…was out of hospital…出院Personal History (Per. H.)/ Social History 个人史/社会史⏹Note: menstruation经期（天）menstrual periodmenarche age——————age of menopause（初潮年龄menstrual cycle （绝经年龄）月经周期（天）⏹Characteristics of languageDeclarative sentences and elliptical sentences are usually used, and present tense, past tense and past perfect tense are adopted. Family History (F. H.) 家族史⏹Common expressions①…be living and well./…be in good health./ …be well with no evidence of (illness). 健在②(There is) No famil y history of (disease)./ (There was) No (disease) in one’s family.无（病）家族史③There was no case of (disease) in his//her family./ No one in his/her family experienced (disease) 家族成员未曾患过……④Family history showed/revealed… 家族史显示……⑤There was a familial/he reditary tendency to…/ There was a strong family history of…/There was a high incidence of…in the family. 家族有……倾向/发病率⑥There was a high prevalence of…in the family 家族中……患病率高⑦Positive for (some disease) in (some one). 曾患过……⑧…as a family charac teristic. 家族特点⑨FH: Noncontributory 家族史无意义Allergies 过敏史Common expressions①NKDA (no known drug allergies) 无过敏史②allergy, allergic, hypersensitive, hypersensitivity 过敏③sensitive, sensitivity, sensible, sensibility 敏感④allergic reaction 过敏反应⑤be al lergic to… 对……过敏⑥be sensible to… 对……敏感⑦have no history of allergy to…; have no history of…sensibility 对……有（无）过敏史⑧have an allergic diathesis 具有过敏体质⑨have no allergic reaction to any drugs 对用过的药物无过敏反应⑩show sensibility to…(e.g. house dust) 对……（如室内灰尘）过敏Physical Examination (P. E.)体格检查，查体1) Physical data/physical signs 一般资料/生理指标2) General appearance 一般情况或全身状态3) Head, eyes, ear, nose and throat (HEENT) 头眼与耳鼻喉4) Chest, heart and lungs 胸部与心肺5) Abdomen 腹部6) Extremities 四肢7) Nervous system, neurological (CNS/Neuro) 神经系统8) Musculoskeletal 骨骼肌肉系统9) Genitourinary 泌尿生殖系统Physical data/physical signs 一般资料/生理指标①Temperature (T.) 体温position: oral temperature 口温；axillary temperature 腋温；rectal temperature 肛温unit: Celsius, ℃; Fahrenheit, ℉Format: T 38 ℃(or 100.4℉)Pattern: The temperature is 38 ℃(or 100.4 ℉) taken by mouth/ by rectum/ by axilla.②Pulse (P.) 脉搏Format: P 80/min(or P80)Pattern: Pulse 80 per minute.The pulse numbered/beat/measured 80/min.③Respiration/ Respiratory Rate (R.) 呼吸Format: R 20/minCommon expressions:The respirations are 21 per minute.呼吸每分钟21次。