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. 第一部分 病人身份Identification Name 姓名 Sex 性別 Age 年齡 Occupation 職業(yè) Date of birth 出生日期 Marriage (Marital status) 婚姻 Race 民族 Place of birth (Birth place) 籍貫 Identification No.(code of ID card No.) 身份證號碼 Department of work and TEL. No. (Unit and Business phone No.) 工作單位及電話 Home address and phone No. 家庭住址及電話 Post code 郵政編碼 Person to notify (Correspondent) and phone No. 聯(lián)系人及電話 Source (Complainer;offerer;supplier;provider) of history 病史陳術者 Reliability of history 病史可靠程試 Medical security (Type of payment) 醫(yī)療費用 Type of admission (Patient condition) 住院類別(入院時病情) Medical record No. 病歷號 Clinic diagnosis 門診診斷 Date of admission (admission date) 入院日期 Date of record 記錄日期1、年齡的表示方法(以36歲為例)36 years old (y/o)Age 3636 year-oldThe age of 3636 years of age2、性別的表示方法 Male, 男性 Female, 女性3、職業(yè)的表示方法工人Worker 退休工作Retired worker農民Farmer (peasant) 干部Leader (cadre)行政人員administrative personnel (staff)職員staff member 商人Trader (Businessman)教師Teacher 學生Student 醫(yī)生Doctor藥劑師Pharmacist護士Nurse 軍人Soldier 警察Policeman工程師Engineer 技術員Technician 家政人員Housekeeper家庭主婦Housewife 營業(yè)員Assistant 服務員Attendant售票員Conductor 4、民族的表示方法 漢Han 回Hui 蒙Meng 藏Tibetan朝鮮Korean美國人American 日本人Japanese 英國人Britisher5、醫(yī)療費用的表示方法 Self pay (Individual medical care) 自費 Government insruance (Public medical care) 公費 Insurance 保險 Local insurance 本地醫(yī)保 Non-local in surance 外地醫(yī)保 Labor protestion care 勞保6、婚姻狀況的表示方法 Married 已婚 Single (Unmarried) 未婚 Diverced 離婚 Widow 寡婦 Widower 鰥夫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 無法獲得8、住址的表示方法NO.3,Qing Chun Road East,Hangzhou, Zhejiang 浙江省杭州市慶春東路3號XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province. 浙江省諸暨市(縣)城關鎮(zhèn)新東村9、病史陳述者的表示方法 Patient himself (herself) 患者本人 Her husband 患者的丈夫 His wife 患者的妻子 Patients colleague 患者的同事 Patients neighbor 患者的鄰居 Patients Kin (Mother; Son; daughter;brother;Sister) 患者的親屬(父親、母親、兒子、女兒、兄弟、姐妹) Taximan 出租車司機 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)(美國)2002年10月1日1-10-2002(1/10/2002; 1 Oct.,2002; 1st of Oct.,2002) (英國)11、住院類別的表示方法 Emergent (Emergency call) 急診 Urgent 危重 Elective (General) 一般(普通)12、入院時病情的表示方法 Stable 穩(wěn)定 Unstable 不穩(wěn)定 Relative stable 相對穩(wěn)定 Critical (Imminent) 危重 Fair (General) 一般第二部分 主訴Chief Complaint1、主訴的表示方法:癥狀+時間(Symptom+Time)癥狀+for+時間如: Chest pain for 2 hours 胸痛2小時癥狀+of+時間如: Nausea and vomiting of three days duration 惡心嘔吐3天癥狀+時間+in duration如: Headache 1 month in duration 頭痛1月時間+of+癥狀如: Two-day history of fever 發(fā)熱2天2、常見癥狀 Fever 發(fā)熱 Pain 疼痛 Edema 水腫 Mucocutaneous hemorrhage (bleeding) 皮膚粘膜出血 Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath) 呼吸困難 Cough and expectoration (Sputumhlegm) 咳嗽和咯痰 Hemoptysis 咯血 Cyanosis 紫紺 Palpitation 心悸 Chest discomfort 胸悶 Nausea (Retch;Dry Vomiting)and Vomiting 惡心和嘔吐 Hematemesis (Vomiting of blood) 嘔血 Hematochezia (Hemafecia) 便血 Diarrhea 腹瀉 Constipation (Obstipation) 便秘 Vertigo (Giddiness; Dizziness) 眩暈 Jaundice (Icterus) 黃疸 Convulsion 驚厥 Disturbance of consciousness 意識障礙 Hematuria 血尿 Frequent micturition,urgent micturition and dysuria 尿頻,尿急和尿痛 Incontinence of urine 尿失禁 Retention of urine 尿潴留(1)發(fā)熱的表示方法 Infective (Septic)fever 感染性發(fā)熱 Non-infective (Aseptic)fever 非感染性發(fā)熱 Dehydration (Inanition)fever 脫水熱 Drug fever 藥物熱 Functional hypothermia 功能性低熱 Absorption fever 吸收熱 Central fever 中樞性發(fā)熱 Fever type 熱型 Continuous fever 稽留熱 Remittent fever 馳張熱 Intermittent fever 間歇熱 Undulant fever 波狀熱 Recurrent fever 回歸熱 Periodic fever 周期熱 Irregular fever 不規(guī)則熱 Ephemeral fever 短暫熱 Double peaked fever 雙峰熱 Fever of undetermined(unknown) origin, FUO 不明原因發(fā)熱 Rigor (shivering;chill;shaking chill;ague) 寒戰(zhàn) Chilly Sensation (Fell chilly;cold fits;coldness) 畏寒 Ultra-hyperpyrexia 超高熱 Hyperthermia (A high fever;hyperpyrexia;ardent fever) 高熱 Moderate fever 中度發(fā)熱 Hypothermia (Low-grade fever;slight fever;subfebrile temperature) 低熱 Become feverish (Have a temperature) 發(fā)熱 Crisis 驟降 Lysis 漸降 Typhoid fever 傷寒熱 Rheumatic fever 風濕熱 Cancerous fever 癌性發(fā)熱 Fervescence period 升熱期 Defervescence period 退熱期 Persistent febrile period 持續(xù)發(fā)熱期(2)疼痛的表示方法 Backache (Back pain) 背痛 Lumbago 腰痛 Headache 頭痛 Vasomotor headache 血管舒縮性頭痛Post-traumatic headache 創(chuàng)傷后頭痛Migraine headache 偏頭痛 Cluster headache 叢集性頭痛 Chest pain 胸痛 Precardial pain 心前區(qū)痛 Retrosternal pain 胸骨后痛 Abdominal pain (Stomachache) 腹痛 Acrodynia (pain in limbs) 肢體痛 Arthrodynia (Arthralgia) 關節(jié)痛 Dull pain 鈍痛 Sharp pain 銳痛 Twinge pain 刺痛 Knife-like pain (Piercing pain) 刀割(刺)樣痛 Aching pain 酸痛 Burning pain 燒灼痛 Colicky (Griping;cramp) pain 絞痛 Colic 絞痛 Bursting pain 脹痛(撕裂痛) Hunger pain 饑餓痛 Tic pain 抽搐痛 Bearing-down pain 墜痛 Shock-like pain 電擊樣痛 Jumping pain 反跳痛 Tenderness pain 觸痛(壓痛) Girdle-like pain 束帶樣痛 Wandering pain 游走性痛 Throbbing pain 搏動性痛 Radiating pain 放射性痛 Cramping pain 痙攣性痛 Boring pain 鉆痛 Intense pain 劇痛 Writhing pain 痛得打滾 Dragging pain 牽引痛 Labor pain 陣痛 Cancerous pain 癌性疼痛 Referred pain 牽涉痛 Persistent pain (Unremitting pain) 持續(xù)性痛 Constant pain 經常性痛 Intermittent pain 間歇性痛(3)水腫的表示方法 Mucous edema (Myxedema) 粘液性水腫 Cardiac (Cardiogenic) edema 心源性水腫 Nephrotic (renal) edema 腎源性水腫 Hepatic edema 肝源性水腫 Alimentary (Nutritional) edema 營養(yǎng)不良性水腫 Angioneurotic edema 血管神經性水腫 Pitting 凹陷性 Nonpitting 非凹陷性 Localized (Local) edema 局限性水腫 Generalized edema (Anasarca) 全身性水腫 Hydrops 積水 Elephantiasic crus 橡皮腫 Cerebral(Brain) edema 腦水腫 Pulmonary edema (Hydropneumonia0 肺水腫 Hydrocephalus 腦積水 Edema of endoscrinopathy 內分泌病性水腫 Invisible (Recessive) edema 隱性水腫 Frank edema 顯性水腫 Inflammatory edema 炎性水腫 Idiopathic edema 特發(fā)性水腫 Cyclical edema 周期性水腫 Ascites (Abdominal effusion;hydroperiotoneum) 腹水 Pleural effusion (Hydrothorax) 胸水 Pericardial effusion (Hydropericardium) 心包積液 Bronchoedema 支氣管水腫 Slight (Mild) 輕度 Moderate 中度 Serious 重度 Transudate 漏出液 Exudate 滲出液(4)呼吸困難的表示方法 Cardiac dyspnea 心原性呼吸困難 Inspiratory 吸氣性 Expiratory 呼氣性 Mixed 混合性 Obstructive 梗阻性 Dyspnea at rest 靜息時呼吸困難 Dyspnea on exertion 活動時呼吸困難 Dyspnea on lying down 躺下時呼吸困難 Paroxysmal nocturnal dyspnea,PND 夜間陣發(fā)性呼吸困難 Orthopnea 端坐呼吸 Asthma 哮喘 Cardiac asthma 心源性哮喘 Bronchial asthma 支氣管性哮喘 Hyperpnea 呼吸深快 Periodic breathing 周期性呼吸 Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)氣促 Bradypnea (Slow breathing) 呼吸緩慢 Irregular breathing 不規(guī)則呼吸(5)皮膚粘膜出血的表示方法 Bleeding spots in the skin 皮膚出血點 Petechia 瘀點 Eccymosis 瘀斑 Purpura 紫癜 Splinter hemorrhage 片狀出血 Oozing of the blood (Errhysis) 滲血 Blood blister (Hemophysallis) 血皰 Hemorrhinia (Nasal bleeding) 鼻衄 Ecchymoma 皮下血腫(6)咳嗽與咯痰的表示方法 Dry cough (Nonproductive cough;hacking cough) 干咳 Sharp cough 劇咳 Wet cough (Moist cough) 濕咳 Productive cough (Loose cough) 排痰性咳 Chronic cough 慢性咳嗽 Irritable cough 刺激性咳嗽 Paroxysmal cough 發(fā)作性(陣發(fā)性)咳嗽 Cough continually 持續(xù)性咳嗽 Spasmodic cough 痙攣性咳嗽 Whooping cough 百日咳 Winter cough 冬季咳 Wheezing cough 喘咳 Short cough 短咳 Distressed cough 難咳 Shallow cough 淺咳 Droplet 飛沫 Frothy sputum 泡沫樣痰 Bloody sputum 血痰 Mucous (Mucoid) sputum 粘液樣痰 Purulent sputum 膿痰 Mucopurulent sputum 粘液膿性痰 White (Yellow,green) sputum 白(黃,綠)痰 Fetid (Foul) sputum 惡臭痰 Iron-Rust (Rusty) sputum 鐵銹色痰 Chocolate coloured sputum 巧克力色痰 Thick sputum 濃痰 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)內臟出血的表示方法 Goldsteins hemoptysis戈耳斯坦氏咯血 Massive hematemesis大量嘔血 Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)鼻衄 Hematuria 血尿 Initial hematuria 初血尿 Idiopathic hematuria 特發(fā)性血尿 Painless hematuria 無痛性血尿 Terminal hematuria 終末性血尿 Gross (Macroscopic) hematuria 肉眼血尿 Microscopic hematuria 鏡下血尿 Hematuria in the whole process of urination 全程血尿 Gingival bleeding (Ulaemorrhagia;gum bleeding) 牙齦出血 Hematochezia 便血 Bloody stool 血便 Black stool (Melena) 黑便 Tarry stool 柏油樣便 Bleeding following trauma 外傷后出血 Spontaneous bleeding 自發(fā)性出血 Bleeding Continuously 持續(xù)出血 Occult blood,OB 隱血 Hematobilia 膽道出血 Hemathorax 血胸 Hemarthrosis 關節(jié)積血 Hematocoelia 腹腔積血 Hematoma 血腫 Hemopericardium 心包積血 Cerebral hemorrhage 腦出血 Subarachnoid hemorrhage(SAH) 蛛網膜下腔出血 Excessive (Heavy) menstrual flow with passage of clots 月經量多伴血塊 Mild (Moderate) menses 月經量少(中等) Painless Vaginal bleeding 無痛性陰道出血 Postcoital bleeding 性交后出血 Pulsating bleeding 搏動性出血 Post-operation wound hemorrhage 術后傷口出血 Excessive bleeding after denal extraction 拔牙后出血過多(8)紫紺的表示方法 Congenital cyanosis 先天性紫紺 Enterogenous 腸源性 Central 中樞性 Peripheral 周圍性 Mixed 混合性 Acrocyanosis 指端紫紺(9)惡心與嘔吐的表示方法 Vomiturition (Retching) 干嘔 Feel nauseated 惡心感 Postprandial nausea 飯后惡心 Hiccup 呃逆 Sour regurgitation 返酸 Fecal (Stercoraceous) vomiting 吐糞 undigested food Vomiting 吐不消化食物 Bilious Vomiting 吐膽汁(10)腹瀉與便秘的表示方法 Moning diarrhea 晨瀉 Watery (Liquid)diarrhea 水瀉 Mucous diarrhea 粘液瀉 Fatty diarrhea 脂肪瀉 Chronic (Acute) 慢性(急性) Mild diarrhea 輕度腹瀉 Intractable (Uncontrolled)diarrhea 難治性腹瀉 Protracted diarrhea 遷延性腹瀉 Bloody stool 血梗 Frothy stool 泡沫樣便 Formless (Formed)stool 不成形(成形)便 Loose (Hard) stool ?。ㄓ玻┍?Rice-water stool 米泔樣便 Undigested stool 不消化便 Dysenteric diarrhea 痢疾樣腹瀉 Inflammatory diarrhea 炎癥性腹瀉 Osmotic 滲透性 Secretory 分泌性 Malabsorption 吸收不良性 Lienteric 消化不良性 Pancreatic diarrhea 胰性腹瀉 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 器質性便秘 Habitual constipation 習慣性便秘 Have a tendency to be constipated 便秘傾向(11)黃疸的表示方法 Latent (occult) jaundice 隱性黃疸 Clinical jaundice 顯性黃疸 Nuclear icterus 核黃疸 Physiologic icterus 生理性黃疸 Icterus simplex 傳染性黃疸 Toxemic icterus 中毒性黃疸 Hemolytic 溶血性 Hepatocellular 肝細胞性 Obstructive 阻塞性 Congenital 先天性 Familial 家族性 Cholestatic 膽汁淤積性 Hematogenous 血源性 Malignant 惡性 Painless 無痛性(12)意識障礙的表示方法 Somnolence 嗜睡 Confusion 意識模糊 Stupor 昏睡 Coma 昏迷 Delirium 譫妄 Syncope (swoon; faint) 暈厥 Drowsiness 倦睡(13)排尿的表示方法 Enuresis (Bed-wetting) 遺尿 Anuria 無尿 Emiction interruption 排尿中斷 Interruption of urinary stream 尿線中斷 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) 尿頻 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) 排尿困難 Small urinary stream 尿線細小 Void with a good stream 排尿通暢 Guttate emiction (Dribbling following urination;terminal dribbling) 滴尿 Bifurcation of urination 尿流分叉 Residual urine 殘余尿 Extravasation of urine 尿外滲 Stress incontinence 壓力性尿失禁 Overflow incontinence 溢出性尿失禁 Paradoxical in continence 反常性尿失禁3少見癥狀 Weekness( Debility; asthenia; debilitating) 虛弱(無力) Fatigue (Tire; lassitude) 疲乏 Discomfort (Indisposition; malaise) 不適 Wasting (thin; underweight; emaciation; lean) 消瘦 Night sweating 盜汗 Sweat (Perspiration) 出汗 Cold sweat 冷汗 Pruritus (Iching) 搔癢 Asthma 氣喘 Squeezing (Tightness; choking; pressing) sensation of the chest 胸部緊縮(壓榨)感 Intermittent claudication 間歇性跛行 Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis) 吞咽困難 Epigastric (Upper abdominal) discomfort 上腹部不適 Anorexia (Sitophobia) 厭食 Poor appetite (Loss of appetite) 納差 Heart-burn( Pyrosis) 胃灼熱 Stomachache( Pain in stomach) 胃部痛 Periumbilial pain 臍周痛 Belching (Eructation) 噯氣 Sour regurgitation 返酸 Abdominal distention(bloating) 腹脹 Pass gas( Break wink) 肛門排氣 Small(Large) stool 大便少(多) Expel(Pass) worms 排蟲 Pain over the liver 肝區(qū)痛 Lumbago 腰痛 Pica(Parorexia; allotriophagy) 異食癖 Dysmenorrhea 痛經 Menoxenia (Irregular menstruation) 月經不調 Polymenorrhea (Epimenorrhea) 月經過頻 Oligomenorrhea 月經過少 Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea) 經量過多 Hypomenorrhea (Scantymenstruation) 經量過少 Menopause (Menostasia; menostasis) 絕經 Amenorrhea (Menoschesis) 閉經 Leukorrhagia 白帶過多 Asexuality (lack of libido) 無性欲 Hyposexuality 性欲低下 Hypersexuality 性欲亢進 Prospermia (Ejaculatio praecox) 早泄 Impotency (impotence) 陽萎 Nocturnal emission (Spermatorrhea) 遺精 Lack of potency 無性交能力 Hair loss 脫發(fā) Joint pain (Arthralgia; arthrodynia) 關節(jié)痛 Polydipsia (Excessive thirst) 多飲(煩渴) Polyphagia (Excessive appetite; hyperorexia; bulimia) 多食 Cold (Heat) intolerance 怕冷(熱) Dwarfism (Excessive height) 身材矮?。ǜ叽螅?Excessive sweating 多汗 Hands tremble 手抖 Obesity (Fatty) 肥胖 Agitation (Anxiety;nervous irritability) 焦慮(憂慮) Mania 躁狂 Hallucination 幻覺 Aphasia (Logopathy) 失語 Amnesia (Poor memorization;memory deterioration) 記憶力下降 Hemianesthesia 偏身麻木 Formication 蟻走感 Tingling 麻刺感 Hyperpathia 痛覺過敏 Hypalgesia 痛覺減退 Illusion 錯覺 Hemiplegia 半身不遂 Insomnia (Poor sleepness;sleeplessness) 失眠 Nightmare 多夢 Numbness 麻木 Pain in limbs (Acrodynia) 肢體痛 Limitation of motion 活動受限 Tetany 手足抽搐 Discharge of pus 流膿 Blurred vision(Hazy vision;blurring of vision; dimness of vision)視物模糊 Burning (Dry) sensation 燒灼(干燥)感 Tearing (Dacryorrhea;Lacrimation) 流淚 Double vision (Diplopia) 復視 Strabismus 斜視 Hemianopia 偏盲 Tired eyes (Eyestrain) 眼疲勞 Foreign body sensation 異物感 Lose the sight (Lose of vision) 失明 Diminution of vision 視力減退 Nictition 眨眼 Ophthalmodynia (Eye-ache;ocular pain) 眼痛 Photophobia 畏光 Spots before the eyes 眼前黑點 Deafness(Anacusia) 耳聾 Auditory dysesthesia 聽力減退 Otalgia (Otodynia;pain in the ear ;ear-ache) 耳痛 Stuffy feeling in the ear 耳閉氣 Tinnitus 耳鳴 Outophony 自聲過強 Nasal obstruction (blockage) 鼻塞 Dryness of the nose 鼻干燥 Rhinorrhea (Snivel;Nasal discharge) 流鼻涕 Sneezing 打噴嚏 Snoring 打鼾 Hyposmia (Reduction of the sense of smell) 嗅覺減退 Anosmia (Complete loss of sense of smell) 嗅覺喪失 Dysphonia 發(fā)音困難 Hoarseness 聲嘶 Pain on swallowing 吞咽痛 Saliva dribblies from the mouth 流涎 Troaty voice 聲音沙啞 Stridor 喘鳴 Red and swollen 紅腫 Scurf 頭皮屑 Show 見紅 Amniotic fluid escaped 破水 Uterine contraction 宮縮 Acalculia 計算不能 Apathy 情感淡漠 Delusion 妄想第三部分 現(xiàn)病史History of present illness (HPI/PI)現(xiàn)病史書寫的重點包括:一、主訴中癥狀的詳細描述;二、疾病的發(fā)展過程;三、診療經過;四、目前的一般情況。1、誘因無誘因下With no inducing factors無明顯誘因下Under no obvious predisposing causes感冒一周后After getting (catching) common cold for 1 week2、癥狀出現(xiàn)的敘述有癥狀suffer from have an attack of have(fell) begin to fell a feeling (sensation) of complain (of) sensation (feeling) in (of) 發(fā)熱have a temperature (become feverish)在情況下發(fā)生 活動時呼吸困難dyspnea on exertion 躺下后即出現(xiàn)咳嗽Cough occurs soon after lying與有(無)關 與有關be associated with 與有關have (make) relation to 與無關have (make)no relation to在情況下加重(減輕) 餐后加重become worse after taking meals 站立后緩解be relieved by standing up 隨呼吸和咳嗽而加重become more severe with breathing and cough伴有 be accompanied by3、起病方式急性腹痛acute abdominal pain慢性低熱chronic lower fever暴發(fā)性發(fā)病the onset was fulminating驟起胸痛an explosive onset of chest pain突然起病伴高熱t(yī)he onset was sudden with high fever突發(fā)突止attacks began and ended abruptly因而突然起病the attack is precipitated by很快發(fā)生暈厥syncope occured rapidly逐漸出現(xiàn)咳嗽咳痰gradual onset of cough and sputum偶而occasionally (sporadically, accidentally)反復胸悶心悸recurrent (bouts of) chest discomfort and palpitation一過性發(fā)作transitory attack連續(xù)胸痛chest pain continually時重時輕waned and waxed時好時壞hang in the balance不停地咳嗽have a fit of cough發(fā)作性呼吸困難paroxysmal short of breath頻繁咳嗽cough frequently (very often)持續(xù)性(間歇性)persistent (intermittent)頻發(fā)胸痛frequent episodes of chest pain持續(xù)不變be steady4、病情變化描述癥狀好轉 fell better than beforetake a favorable turntake a turn for the betterimprovemake favorable progressturn for the betterchange for the betterbe better癥狀減輕 alleviatereducepalliatediminishease(lighten)mitigate癥狀消失 disappearsubsideregressclear upvanishdissolvedi
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