病歷 case histroy
一般事項(xiàng) date of admission /marital status /present address /correspondence / occupation
主訴 chief complaints
現(xiàn)病史 present illness / history of present illness
既往史 past medical history
家族史 family history
個(gè)人病史 personal history / social history
曾用藥物 medications
過敏史 allergies
系統(tǒng)回顧 system review / review of system
體檢 physical examination
一般資料 physical data 生理指標(biāo)physical signs
一般狀況或全身狀況 general appearance
頭眼與耳鼻喉 head ,eyes,ear,nose,throat ,略作heent.
胸部與心肺 CHEST,heart,and lungs
腹部 abodoms
四肢extremities
神經(jīng)系統(tǒng)nervous system,Neurological,略作CNC或Neuro,
骨骼肌系統(tǒng) Musculoskeletal
泌尿生殖系統(tǒng) Genitourinary
化驗(yàn)室資料laboratory data/ studies /diagnosis
血液檢查 blood test
化學(xué)7項(xiàng)指標(biāo) chem.-7
心腦電圖 electrocardiogram / electroencephalogram , 略作 EKG/EEG
X線檢查與x光片 X-ray examination, x-ray slides,
計(jì)算機(jī)X線斷層掃描與核磁共振掃描資料 computerized x-ray tomography and nuclear magnetic resonance spectroscopy dta. CT AND NMR
其他檢查資料 other lab data
印象與診斷 impression and diagnosis
住院治療情況 hospital course
出院醫(yī)囑 discharge instructions / recommendations
出院后用藥 discharge medications
1) 一般病情:
He feels headache, nausea and vomiting. (他覺得頭痛、惡心和想吐。)
He is under the weather. (他不舒服，生病了。)
He began to feel unusually tired. (他感到反常的疲倦。)
He feels light-headed. (他覺得頭暈。)
She has been shut-in for a few days. (她生病在家?guī)滋炝恕?
Her head is pounding. (她頭痛。)
His symptoms include loss of appetite, weight loss, excessive fatigue, fever and chills. (他的癥狀包括沒有食欲、體重減輕、非常疲倦、發(fā)燒和發(fā)冷。)
He feels exhausted or fatigued most of the time. (他大部份時(shí)間都覺得非常疲倦。)
He has been lacking in energy for some time. (他感到虛弱有段時(shí)間了。) { 楓下論壇 .net/forum }
He feels drowsy, dizzy and nauseated. (他覺得昏昏欲睡，頭暈?zāi)垦：拖胪隆?
He feels as though everything around him is spinning. (他感到周圍的東西都在打轉(zhuǎn)。)
He has noticed some loss of hearing. (他發(fā)覺聽力差些。)
She has some pains and itching around her eyes. (她眼睛四周又痛又癢。)
(2) 傷風(fēng)感冒：
He has been coughing up rusty or greenish-yellow phlegm. (他咳嗽帶有綠黃色的痰。)
His eyes feel itchy and he has been sneezing. (他眼睛發(fā)癢，而且一直在打噴嚏。)
He has a fever, aching muscles and hacking cough. (他有發(fā)燒，筋骨酸痛和常�？人浴�) (hacking = constant)
He coughed with sputum and feeling of malaise. (他咳嗽有濃痰，而且覺得很虛弱。) (malaise = debility)
He gets a cold with a deep hacking cough. (他傷風(fēng)咳嗽。)
He has a headache, aching bones and joints. (他頭痛，骨頭、關(guān)節(jié)也痛。)
He has a persistent cough. (他不停地在咳。) 或
He has bouts of uncontrollable coughing. (他一陣陣的咳嗽，難以控制。)
He has hoarse and has lost his voice sometimes. (他聲音嘶啞，有時(shí)失聲。)
He has a sore throat and a stuffy nose. (他嗓子疼痛而且鼻子不通。)
His breathing is harsh and wheezy. (他呼吸時(shí)，有氣喘似的呼哧呼哧作響。)
He has a stabbing pain that comes on suddenly in one or both temples. (有時(shí)突然間太陽穴刺痛。)
He has a runny nose, sneezing or a scratchy throat. (他流鼻水，打噴嚏和喉嚨沙啞。)
(3) 女性疾�。�
She has noticed one lump in her breast. (她發(fā)覺乳房有個(gè)腫塊。)
There is a hard, swollen lump on her right breast. (她右乳房有腫塊。)
Her left breast is painful and swollen. (她左乳房疼痛且腫大。)
She has heavy bleeding with her periods. (她月經(jīng)來的很多。)
Her vaginal discharge is white or greenish-yellow and unpleasant smelling. (她陰道分泌物帶白色或綠黃色，而且氣味不好。)
She has noticed occasional spotting of blood between periods. (在月經(jīng)來的前后，她有時(shí)也發(fā)覺有滴滴達(dá)達(dá)的流血。)
She has some bleeding after intercourse. (性交后有出血。)
She feels some vaginal itching. (她感到陰部發(fā)癢。)
She has painful periods and abnormal vaginal discharge. (她月經(jīng)來時(shí)疼痛，而且陰道有不正常的分泌物。)
(4)男性疾�。�
He urinates more frequently than usual.（他小便比平時(shí)多。)
He has difficulty controlling his bladder.（他很難控制小便。)(bladder 是膀胱)
There are some lumps on his testicles. （他的?丸有些硬塊。)
He has had burning or pain when he urinates.（他小便時(shí)感到發(fā)燙和疼痛。)
He is passing less urine than usual.（他小便比平時(shí)少。)
He has had painless swelling in his scrotum.（他的陰囊有不痛的腫大。)
He feels lack of interest in sex.（他自覺對性的興趣大減。)
He has difficulty starting his urine flow.（他小便不暢通。)
His urine stream is very weak and slow.（他小便流動(dòng)得很慢很弱。)
He dribbles a little urine after he has finished urinating.（他小便后，還會有少量零星地滴下。)
He has had some discharge from his penis.（他的陰莖排出一些流膿。)
His urine is cloudy and it smells strong.（他的小便混濁，而且氣味不好。)
He has a dull heavy ache in the crotch.（他的胯部感到隱痛。)
He has a small leakage of urine when he coughs or sneezes.（他咳嗽或打噴嚏時(shí)，會有點(diǎn)泄尿。)
He has trouble urinating.（他小便有困難。)
(5) 手腳毛�。�
His both hands and feet ache all over. (他兩手兩腳都很酸痛。)
He has pain on the sole of his feet. (他腳底很痛。)
There is a wart-like lump on the sole of right foot. (我右腳底有個(gè)像肉疣般的硬塊。)
His ankles look puffy and they pit when he presses them with his finger. (他的足踝好象腫了，用手按，就有小坑痕。) (pit = small dent form)
(句里的 they 和 them 都是指 ankles)
The pain in his left foot is accompanied by redness and swelling. (左腳酸痛，并有紅腫。)
The joints near his fingernails and knuckles look swollen. (指頭和指節(jié)旁邊的關(guān)節(jié)，似乎有腫大。)
He has numbness and tingling in his hands and fingers. (他的手和指頭感到麻木和刺痛。)
His legs become painful following strenuous exercise. (激烈運(yùn)動(dòng)后，他的腿就痛。)
His knee is misshapen or unable to move. (他的膝蓋有點(diǎn)畸形，也不能動(dòng)。)
There are some swellings in his armpit. (他的腋窩腫大。)
He is troubled with painful muscles and joints. (他的筋骨和關(guān)節(jié)都痛。)
She is troubled by the pains in the back and shoulders. (她的后背和肩膀都痛。)
His knee has been bothering him for some time. (他的膝蓋不舒服，已有一段時(shí)間了。)
(6) 睡眠不好：
He is sleeping poorly.（他睡不好)
He has difficulty in sleeping, inability to concentrate.（他不易入睡，也難集中精神。)
It is usually hard for her to fall asleep when she goes to bed at night.（她晚上就寢，很難入睡。)
He wakes during the night or early morning and finds it difficult to fall asleep again.（他晚間或清早醒來后，再也不能入睡。)
He has nightmares occasionally.（他有時(shí)做噩夢。)
(7) 呼吸方面：
His breathing has become increasingly difficult.（他呼吸越來越困難。)
He has to breathe through his mouth.（他要用口呼吸。)
He is short of breath, even when he has not been exercising, he is breathless.（他喘氣；即使不運(yùn)動(dòng)，他也是上氣不接下氣。)
His cough is more like wheezing.（他的咳嗽有呼哧呼哧的響聲。)
His cough is dry, producing no phlegm.（他是干咳，沒有痰。)
He has coughed up blood.（他咳嗽有血。)
His nose stuffed up when he had a cold.（他感冒時(shí)鼻子就不通。)
He coughs up a lot of phlegm (thick spit) on most days.（他多半時(shí)間咳出濃濃的痰。)
He has a feeling of tightness in the chest or a feeling that he is suffocating.（他胸部覺得悶悶的，好象透不過氣來。)
(8) 口腔毛�。�
He has pain in his teeth or jaw. (他的牙齒和下巴疼痛。)
He has some problems with his teeth. (他牙齒有問題。)
The tooth hurts only when he bites down on it. (他咬東西時(shí)，牙齒就痛。)
(動(dòng)詞時(shí)態(tài)：hurt, hurt, hurt; bite, bit, bit)
His gums are red and swollen. (他的牙床紅腫。)
His tongue is red and sore all over. (他的舌頭到處紅和痛。)
His breath smells bad and he has a foul taste in his mouth. (他口里有怪味。)
His gums do bleed. (他牙床有出血。)
He has some sore swellings on his gum or jaw. (他的牙床和下巴腫痛。)
He has sore places on or around the lip. (他的嘴唇和周圍都很痛。)
There are cracks at the corners of his mouth. (他的嘴巴角落破了。)
There are some discolored areas inside on his tongue. (他舌頭里邊有些地方顏色怪怪的。)
(9) 腸胃毛�。�
He has a bloated, uncomfortable feeling after meal. (他飯后肚子覺得脹脹的，很不舒服。) 或
He feels bloated after eating.
He has bouts of abdominal pain. (他有一陣陣的肚痛。)
He feels bloated in his abdominal area. (他感到肚子脹脹的。)
(注：脹脹的，像「puff up」，但不是真正的腫「swell up」。)
The pain is mainly in the lower (upper) right part of the abdomen. (痛是在肚子下半部。)
He has nausea and vomiting. (他有惡心和嘔吐。)
It is difficult or painful for him to swallow. (他吞下食物時(shí)會痛。)
He has passed more gas than usual. (他放…比平常多。)
He has been constipated for a few days. (他便秘了好幾天。)
He suffers pains when he moves his bowels. (他大便時(shí)很痛。)
He has some bleeding from his rectum. (他的肛門出血。)
He has noticed some blood in his bowel movements. (他發(fā)覺大便時(shí)有些血。)
His bowel movements are pale, greasy and foul smelling. (他大便呈灰白色，含油脂的惡臭。) 或
His bowel movements are grey (or black) in color. (他的大便呈灰白色。)
He has trouble with diarrhea. (他拉肚子。)
(10) 血壓等等：
His blood pressure is really up. (他的血壓很高。)
High blood pressure is creeping up on him.
He has noticed frequent urination, increased thirst and unexpected tireness. (他發(fā)覺常常小便，非�？诳屎透悠＞搿�)
It is a chest pain that gets worse when he bends over or lies down. (他彎腰或躺下時(shí)，胸部更痛。)
He has noticed excessive sweating and unexplained tireness. (他體會到過度的出汗和難以解釋的疲倦。)
He has a sharp pain in one area of his spine. (他的脊椎某部位刺痛。)
He has pain in other joints including hip, knee and ankle. (其它關(guān)節(jié)疼痛包括臀部、膝蓋和腳踝。)
His eyes seem to be bulging. (他的眼睛覺得有點(diǎn)腫脹。)
He has double vision. (他的視線有雙重影子。)
He feels there is a film over his eyes. (他覺得眼里有種薄膜似的東西，擋住視線。)
His vision in the right eye blurred. (他右眼視線模糊不清。)
He has had some earaches lately. (他近來耳朵有點(diǎn)痛。)
He has a repeated buzzing or other noises in his ears. (他耳朵常有嗡嗡的聲音。)
