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1、简明病历书写手册1（英汉对照）简明病历书写手册（英汉对照）郭航远编著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
2、和设备附8、医学院和医院相关名称1Z11-刖5随着我国加入WTO,医疗体制发生了革命性的改变。随着改革开放的深入,外国投资和管理的医院将不断涌现，中外医学交流也日趋频繁，出国学习、进修和援外医疗队的医务人员逐年增多，这就要求医生具有正确书写英文病历的能力。目前，国内供临床医生完成英文病历的参考书很少。签于此，编著者根据美国罗马琳达大学的病历书写要求，结合十余年的国内外工作经验（编者所在的邵逸夫医院是一所由美国专家管理的、与国际接轨的新型综合性医院，有十余年的英文病历书写实践），并参阅一些国内外的相关文献，编写了本手册。本手册按病历书写的顺序进行编写，采用英中对照写法，内容详尽，条理清晰，形式新
3、颖，适用于临床医生、出国人员、实习生和医学院校的学生。在本手册的编写过程中，得到了美国罗马琳达大学医学院和日本福井大学医学院和邵逸夫医院领导的关心和支持。谨以此书献给我的老师、同事、朋友和家人。郭航远2002.11.1于浙江大学医学院第一章病人身份Identification INameJ姓名 Sex性别 Age年龄 Occupation职业 Dateofbirth出生日期 Marriage(Maritalstatus)婚姻 Race民族 Placeofbirth(Birthplace)籍贯 IdentificationNo.(codeofIDcardNo.)身份证号码 Departmento
4、fworkandTEL.No.(UnitandBusinessphoneNo.)工作单位及电话HomeaddressandphoneNo.家庭住址及电话 Postcode邮政编码 Persontonotify(Correspondent)andphoneNo.联系人及电话 Source(Compiainer;offerer;supplier;provider)ofhistory病史陈术者 IReliabilityofhistory病史可靠程试 Medicalsecurity(Typeofpayment)医疗费用 Typeofadmission(Patientcondition)住院类别(入院时
5、病情) MedicalrecordNo.病历号 Clinicdiagnosis门诊诊断 Dateofadmission(admissiondate)入院日期 DateofrecordJ记录日期1、年龄的表示方法(以36岁为例) 36yearsold(yo)Age36 36year-old Theageof36 36yearsofage2、性别的表示方法 Male,男性 Female,2女性3、职业的表示方法工人Worker退休工作Retiredworker农民Farmer(peasant)干部Leader(cadre)行政人员IadminiStratiVepersonnel(staff)职员s
6、taffmember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Conductor4、民族的表示方法 汉Han0Hui 蒙Meng.藏Tibetan 朝鲫KOrean 美国人American 日本人Japanese 英国人Britisher5、医疗费用的表示方法 (Selfpay(Indivi
7、dualmedicalcare)自费 Governmentinsruance(Publicmedicalcare)公费 Insurance保险 Localinsurance本地医保 Non-localinsurance外地医保 Laborprotestioncare劳保6、婚姻状况的表示方法 Married已婚 Single(Unmarried)未婚 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 Notentirely不完全可靠 Unobtainable无法获得8、住址的表示方法N0.3,QingChunR
8、oadEast,Hangzhou,Zhejiang浙江省杭州市庆春东路3号XinDongCun,ChengGuanTown,ZhuJimunicipality,zhejiangprovince.浙江省诸暨市(县)城关镇新东村9、病史陈述者的表示方法 Patienthimself(herself)I患者本人 Herhusband患者的丈夫 Hiswife患者的妻子 Patienfscolleague患者的同事 Patientsneighbor患者的邻居 PatientsKin(Mother;Son;daughter;brother;Sister)患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹)
9、Taximan出租车司机 Trafficpolice交通警察10、日期的表示方法 2002年10月1a10-1-2002(10/1/2002;0ct.l,2002;Oct.lst,2002)(S) 2002年10月1日U-IO-2002(1/10/2002;1Oct.,2002;IStofoCt.,2002)(英国)11、住院类别的表示方法 Emergent(Emergencycall)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Relativestable相对稳定Critical(Imminent)
10、危重Fair(General)一般第二章主诉ChiefCompIaint1、主诉的表示方法：症状+时间(SymPtOm+Time)症状+for+时间如：(Chestpainfor2hours胸痛2小时症状+of+时间如：Nauseaandvomitingofthreedaysduration恶心呕吐3天 症状+时间+induration如:Headache1monthinduration头痛1月 时间+of+症状如：(Two-dayhistoryoffever发热2天2、常见症状 Fever发热 Pain疼痛 Edema水肿 Mucocutaneoushemorrhage(bleeding)皮
11、肤粘膜出血 Dyspnea(Difficulyinbreathing;Respiratorydifficulty;ShOrtofbreath)呼吸困难 Coughandexpectoration(Sputum;Phlegm)咳嗽和咯痰 Hemoptysis咯血 Cyanosis紫组.Palpitation心悸 Chestdiscomfortl胸闷 Nausea(Retch;DryVomiting)andVomiting恶心和呕吐 Hematemesis(Vomitingofblood)呕血 IHematochezia(Hemafecia)J便血 Diarrhea腹泻 Constipation(
12、Obstipation)便秘 Vertigo(Giddiness;Dizziness)眩晕 Jaundice(Icterus)黄疸Convulsion惊厥!Disturbanceofconsciousness意识障碍Hematuria血尿Frequentmicturition,urgentmicturitionanddysuria尿频，尿急和尿痛 Incontinenceofurine尿失禁 Retentionofurine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 Dehydratio
13、n(Inanition)fever脱水热 Drugfever药物热 (Functionalhypothennia功能性低热 Absorptionfever吸收热 Centralfever中枢性发热 Fevertype热型 Continuousfever稽留热 Remittentfever驰张热 (Intermittentfever)间歇热 Undulantfever波状热 Recurrentfever回归热 (Periodicfever周期热 Irregularfever不规则热 Ephemeralfever短暂热 (Doublepeakedfever双峰热 Feverofundetermin
14、ed(unknown)origin,FUO不明原因发热 Rigor(shivering;chill;shakingchill;ague)寒战 ChillySensation(Fellchilly;coldfits;coldness)畏寒 Ultra-hyperpyrexia超高热 Hyperthermia(Ahighfever;hyperpyrexia;ardentfever)高热 Moderatefever中度发热Hypothermia(Low-gradefever;slightfever;subfebriletemperature)低热 Becomefeverish(Haveatemper
15、ature)发热 Crisis骤降 Lysis渐降 Typhoidfever伤寒热 Rheumaticfever风湿热 Cancerousfever癌性发热 Fervescenceperiod升热期 Defervescenceperiod退热期 Persistentfebrileperiod持续发热期(2)疼痛的表示方法 Backache(Backpain)背痛 Lumbago腰痛 Headache头痛 Vasomotorheadache血管舒缩性头痛AIPost-traumaticheadache创伤后头痛 Migraineheadache偏头痛 Clusterheadache丛集性头痛 C
16、hestpain胸痛 Precardialpain心前区痛 Retrostemalpain胸骨后痛 Abdominalpain(Stomachache)腹痛 Acrodynia(paininlimbs)肢体痛 Arthrodynia(Arthralgia)关节痛 Dullpain钝痛 Sharppain锐痛 Twingepain刺痛 Knife-likepain(Piercingpain)刀割(刺)样痛 Achingpain酸痛 Burningpain烧灼痛 Colicky(Griping;cramp)pain绞痛 Colic绞痛 Burstingpain胀痛(撕裂痛) IHungerpain
17、饥饿痛 Ticpain抽搐痛 Bearing-downpain坠痛 Shock-likepain电击样痛 Jumpingpain反跳痛 Tendernesspain触痛(压痛) Girdle-IikepainJ束带样痛 Wanderingpain游走性痛 Throbbingpain搏动性痛 Radiatingpain放射性痛 Crampingpain痉挛性痛 Boringpain钻痛 Intensepain居IJ痛 WrithingpainJ痛得打滚 Draggingpain牵引痛 Laborpain阵痛 Cancerouspain癌性疼痛 Referredpain牵涉痛 Persistent
18、pain(Unremittingpain)持续性痛 Constantpain经常性痛 Intermittentpain间歇性痛(3)水肿的表示方法 Mucousedema(Myxedema)J粘液性水肿 Cardiac(Cardiogenic)edema心源性水肿 Nephrotic(renal)edema肾源性水肿 Hepaticedema肝源性水肿 Alimentary(Nutritional)edema营养不良性水肿 Angioneuroticedema血管神经性水肿!Pitting凹陷性 Nonpitting非凹陷性 Localized(Local)edema局限性水肿 General
19、izededema(Anasarca)J全身性水肿 Hydrops积水 Elephantiasiccrus橡皮肿 Cerebral(Brain)edema脑水肿 Pulmonaryedema(HydropneumoniaO肺水肿 Hydrocephalus脑积水 Edemaofendoscrinopathy内分泌病性水肿 Invisible(Recessive)edema隐性水肿 Frankedema显性水肿 Inflammatoryedema)炎性水肿 Idiopathicedema特发性水肿 Cyclicaledema周期性水肿 Ascites(Abdominaleffusion;hydr
20、operiotoneum)腹水 Pleuraleffusion(Hydrothorax)胸水 Pericardiaeffusion(Hydropericardium)心包积液 Bronchoedema支气管水肿.Slight(Mild)J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 Cardiacdyspnea心原性呼吸困难 Inspiratory吸气性 Expiratory呼气性 IMixedJ混合性 Obstructive梗阻性 Dyspneaatrest静息时呼吸困难 Dyspneaonexertion活动时呼吸
21、困难 Dyspneaonlyingdown躺下时呼吸困难 Paroxysmalnocturnaldyspnea,PND夜间阵发性呼吸困难 OrthopneaJ端坐呼吸 Asthma哮喘 Cardiacasthma心源性哮喘 Bronchialasthma支气管性哮喘 Hyperpnea呼吸深快 Periodicbreathing周期性呼吸 Tachypnea(Rapidorfastbreathing;acceleratedbreathing;shortOfbreath)气促Bradypnea(Slowbreathing)呼吸缓慢 Irregularbreathing不规则呼吸(5)皮肤粘膜出血
22、的表示方法 Bleedingspotsintheskin皮肤出血点 Petechia瘀点 IEccymosisJ瘀斑 Purpura紫瘢 Splinterhemorrhage片状出血 Oozingoftheblood(Errhysis)渗血 Bloodblister(Hemophysallis)血疱Hemorrhinia(Nasalbleeding)鼻蜕 Ecchymoma皮下血肿(6)咳嗽与咯痰的表示方法 Drycough(Nonproductivecough;hackingcough)干咳 Sharpcough剧咳 Wetcough(Moistcough)J湿咳 Productivecou
23、gh(Loosecough)排痰性咳 ChronicCOUgh慢性咳嗽 Irritablecough刺激性咳嗽 Paroxysmalcough发作性(阵发性)咳嗽 Coughcontinually持续性咳嗽 Spasmodiccough痉挛性咳嗽 Whoopingcough百日咳 Wintercough冬季咳 Wheezingcough喘咳 Shortcough短咳 Distressedcough难咳 Shallowcough浅咳 Droplet飞沫 Frothysputum泡沫样痰 BloodysputumI血痰 Mucous(Mucoid)sputum粘液样痰 Purulent叩UtUm脓
24、痰 Mucopurulentsputum粘液脓性痰 White(YelIow,green)sputum白(黄,绿)痰 Fetid(Foul)sputum恶臭痰 Iron-rust(Rusty)sputum铁锈色痰 Chocolatecolouredsputum巧克力色痰 Thicksputum浓痰Thinsputum淡痰 Viscoussputum粘痰 Transparentsputum透明痰 Much(Largeamountsof)sputum大量痰 Moderateamountsofsputum中等量痰 Notmuch(Smallamountsof)sputum少量痰(7)内脏出血的表示方
25、法 Goldsteirfshemoptysis戈耳斯坦氏咯血 Massivehematemesis大量呕血 Epistasis(NosebleediNasalbleeding;Hemorrhiniairhinorrhagia)M HematuriaJ血尿 Initialhematuria初血尿 Idiopathichematuria特发性血尿 Painlesshematuria无痛性血尿 Terminalhematuria终末性血尿 Gross(Macroscopic)hematuria肉眼血尿 Microscopichematuria镜下血尿 Hematuriainthewholeproce
26、ssofurination全程血尿 Gingivalbleeding(Ulaemorrhagia;gumbleeding)牙龈出血 Hematochezia便血Bloodystool血便 Blackstool(Melena)黑便 Tarrystool柏油样便 Bleedingfollowingtrauma外伤后出血 Spontaneousbleeding自发性出血 BleedingContinuously持续出血 Occultblood,OB隐血 Hematobilia胆道出血 HemathoraxJ血胸Hemarthrosis关节积血 Hematocoelia腹腔积血 HematomaJ血肿
27、 Hemopericardium心包积血 Cerebralhemorrhage脑出血 Subarachnoidhemorrhage(SAH)蛛网膜下腔出血 Excessive(Heavy)menstrualflowwithpassageofclots月经量多伴血块 Mild(Moderate)menses月经量少(中等) PainlessVaginalbleeding无痛性阴道出血 Postcoitalbleeding性交后出血 Pulsatingbleeding搏动性出血 Post-operationwoundhemorrhage术后伤口出血.Excessivebleedingafterde
28、nalextraction拔牙后出血过多(8)紫组的表示方法 Congenitalcyanosis先天性紫组 Enterogenous肠源性 Central中枢性 Peripheral周围性 Mixed混合性 Acrocyanosis指端紫组(9)恶心与呕吐的表示方法 Vomiturition(Retching)干呕 Feelnauseated恶心感 Postprandialnausea饭后恶心 Hiccupl呃逆 Sourregurgitation返酸 Fecal(Stercoraceous)vomiting吐粪 undigestedfoodVomiting吐不消化食物 BiliousVom
29、iting吐胆汁(10)腹泻与便秘的表示方法 Moningdiarrhea晨泻 Watery(Liquid)diarrhea水泻 Mucousdiarrhea粘液泻 (Fattydiarrheal脂肪泻 Chronic(Acute)慢性(急性) Milddiarrhea轻度腹泻 Intractable(Uncontrolled)diarrhea难治性腹泻 Protracteddiarrhea迁延性腹泻 Bloodystool血梗 IFrothystool泡沫样便 Formless(Formed)Stool不成形(成物便 Loose(Hard)stool稀(硬)便 Rice-waterstool
30、米泊样便 Undigestedstool不消化便 Dysentericdiarrhea)痢疾样腹泻 Inflammatorydiarrhea炎症性腹泻 Osmotic渗透性 Secretory分泌性 Malabsorption吸收不良性 ILientericJ消化不良性 Pancreaticdiarrhea胰性腹泻 Tenesmus里急后重 Passastool(Haveapassage;openorrelaxthebowel)J解大便 Haveacallofnature便意 Fecalincontinence(Copracrasia)大便失禁 (Functionalconstipation功
31、能性便秘 Organicconstipation器质性便秘 Habitualconstipation习惯性便秘 Haveatendencytobeconstipated便秘倾向（三）黄疸的表示方法 Latent(occult)jaundice隐性黄疸 Clinicaljaundicel显性黄疸 Nuclearicterus核黄疸 Physiologicicterus生理性黄疸 Icterussimplexl传染性黄疸Toxemicicterus中毒性黄疸 Hemolytic溶血性 Hepatocellular肝细胞性 Obstructive阻塞性 Congenital先天性 Familial家
32、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)澹妄 Syncope(swoon;faint)晕厥 Drowsiness倦睡(13)排尿的表示方法 Enuresis(Bed-wetting)遗尿 Anuria无尿 Emictioninterruption排尿中断 Interruptionofurinarystream尿线中断 Nocturia夜尿 01iguria少尿 Polyuria多尿 Pa
33、sswater(Makewater;urinate;micturition)i尿 Frequentmicturition(Frequencyofmicturition;fruquenturination;Pollakiuria)尿频 Urgentmicturition(Urgencyofurinationormicturition)尿急Urodynia(Painonmicturition;painfulmicturition;alginuresis;micturitionpain)尿痛Dysuria(Difficultyinmicturition;disturbanceofmicturitio
34、n)排尿困难 Smallurinarystream尿线细小 Voidwithagoodstream排尿通畅 Guttateemiction(Dribblingfollowingurination;terminaldribbling)滴尿 Bifurcationofurination尿流分叉 Residualurine残余尿 Extravasationofurine尿外渗 Stressincontinence)压力性尿失禁 Overflowincontinence溢出性尿失禁 Paradoxicalincontinence反常性尿失禁3.少见症状 Weekness(Debility;asthen
35、ia;debilitating)虚弱(无力) Fatigue(Tire;lassitude)疲乏 Discomfort(Indisposition;malaise)不适 Wasting(thin;underweight;emaciation;lean)消瘦 Nightsweating盗汗 Sweat(Perspiration)出汗 (Coldsweat冷汗 Pruritus(Iching)搔痒.Asthma气喘 (Squeezing(Tightness;choking;pressing)sensationofthechest1胸部紧缩(压榨)感 Intermittentclaudication
36、间歇性跛行Difficultyinswallowing(Dysphagia;difficultswallowing;acataposis)吞咽困难 Epigastric(Upperabdominal)discomfort上腹部不适Anorexia(Sitophobia)厌食 Poorappetite(Lossofappetite)纳差 Heart-bum(Pyrosis)胃灼热 IStomachacheCPaininstomach)胃部痛 Periumbilialpain脐周痛 Belching(Eructation)暧气 (Sourregurgitation返酸 Abdominaldiste
37、ntion(bloating)腹胀 Passgas(Breakwink)肛门排气 ISmall(Large)stool大便少(多) Expel(Pass)worms排虫Painovertheliver肝区痛 Lumbago)腰痛 Pica(Parorexia;allotriophagy)异食癖 Dysmenorrhea痛经 Menoxenia(Irregularmenstruation)月经不调 Polymenorrhea(Epimenorrhea)月经过频 Oligomenorrhea月经过少 Excessivemenstruation(Menorrhagia;menometrorrhagi
38、a;hypermenorrhea)J经量过多 Hypomenorrhea(Scantymenstruation)经量过少 Menopause(Menostasia;menostasis)名色经 Amenorrhea(Menoschesis)闭经 Leukorrhagia白带过多 Asexuality(lackoflibido)无性欲 Hyposexualityl性欲低下 Hypersexuality性欲亢进 Prospermia(Ejaculatiopraecox)早泄 Impotency(impotence)阳萎 Nocturnalemission(Spermatorrhea)遗精 Lack
39、ofpotency无性交能力HairlossJ脱发 Jointpain(Arthralgia;arthrodynia)关节痛 Polydipsia(Excessivethirst)多饮(烦渴) Polyphagia(Excessiveappetite;hyperorexia;bulimia)多食 Cold(Heat)intolerance怕冷(热) Dwarfism(Excessiveheight)身材矮小(高大) (Excessivesweating多汗 Handstremble手抖 Obesity(Fatty)肥胖 Agitation(Anxiety;nervousirritability
40、)焦虑(忧虑) Mania躁狂 Hallucination幻觉 Aphasia(Logopathy)失语 Amnesia(Poormemorization;memorydeterioration)记忆力下降 Hemianesthesia偏身麻木 Formication蚁走感 Tingling麻刺感 Hyperpathia痛觉过敏 IHypalgesiaJ痛觉减退 Illusion错觉 Hemiplegia半身不遂 Insomnia(PoorSIeePness;SleePIeSSness)失眠 Nightmare多梦 Numbness麻木 Paininlimbs(Acrodynia)肢体痛 (L
41、imitationofmotion活动受限Tetany手足抽搐 Dischargeofpus流脓 Blurredvision(Hazyvision;blurringofvision;dimnessofViSion)视物模糊 Burning(Dry)sensation烧灼(干燥)感 Tearing(Dacryorrhea;Lacrimation)流泪 1Doublevision(Diplopia)J复视 Strabismus斜视 Hemianopia偏盲 Tiredeyes(Eyestrain)J眼疲劳 Foreignbodysensation异物感 Losethesight(Loseofvision)失明!Diminutionofvision视力减退 Nictition眨眼 Ophthalmodynia(Eye-ache;ocularpain)眼痛 Photophobia畏光 Spotsbeforetheeyes眼前黑点 Deafness(Anacusia)耳聋 Auditorydys
