英文病例翻譯

第一部分 病人身份[Identification][Name]姓名[Sex]性別?[Age]年齡?[Occupation]職業(yè)?[Dateofbirth]出生日期?[Marriage（Maritalstatus）]婚姻?[Race]民族?[Placeofbirth(Birthplace)] 籍貫?[IdentificationNo.(codeofIDcardNo.)] 身份證號碼?[DepartmentofworkandTEL.No.(UnitandBusinessphoneNo.)] 工作單位及電話?[HomeaddressandphoneNo.] 家庭住址及電話?[Postcode]郵政編碼?[Persontonotify(Correspondent)andphoneNo.] 聯(lián)系人及電話?[Source(Complainer;offerer;supplier;provider)ofhistory] 病史陳術(shù)者?[Reliabilityofhistory] 病史可靠程試?[Medicalsecurity(Typeofpayment)] 醫(yī)療費用?[Typeofadmission(Patientcondition)] 住院類別（入院時病情）?[MedicalrecordNo.]

病歷號?[Clinicdiagnosis]

門診診斷?[Dateofadmission(admissiondate)]

入院日期

[Dateofrecord]

記錄日期1、年齡的表示方法（以

36歲為例）?36yearsold(y/o)?Age36?36year-old?Theageof36?36yearsofage2、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[Retiredworker]?農(nóng)民[Farmer(peasant)]?干部[Leader(cadre)]?行政人員[administrativepersonnel(staff)]?職員[staffmember]?商人[Trader(Businessman)]?教師[Teacher]?學(xué)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(shù)員[Technician]?家政人員[Housekeeper]?家庭主婦[Housewife]?營業(yè)員[Assistant]?服務(wù)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[Britisher]5、醫(yī)療費用的表示方法?[Selfpay(Individualmedicalcare)]自費?[Governmentinsruance(Publicmedicalcare)]公費?[Insurance]保險?[Localinsurance]本地醫(yī)保?[Non-localinsurance]外地醫(yī)保?[Laborprotestioncare]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?[Notentirely]不完全可靠?[Unobtainable]無法獲得8、住址的表示方法?[NO.3,QingChunRoadEast,Hangzhou,Zhejiang]浙江省杭州市慶春東路3號?[XinDongCun,ChengGuanTown,ZhuJimunicipality,zhejiangprovince.]浙江省諸暨市（縣）城關(guān)鎮(zhèn)新東村9、病史陳述者的表示方法?[Patienthimself(herself)]患者本人?[Herhusband]患者的丈夫?[Hiswife]患者的妻子?[Patient`scolleague]患者的同事?[Patient`sneighbor]患者的鄰居?[Patient`sKin(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?[Trafficpolice]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)精品文庫?2002年10月1日[1-10-2002(1/10/2002;1Oct.,2002;1stofOct.,2002)]( 英國)11、住院類別的表示方法?[Emergent(Emergencycall)] 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?[Relativestable] 相對穩(wěn)定?[Critical(Imminent)] 危重?[Fair(General)] 一般第二部分 主訴[ChiefComplaint]1、主訴的表示方法：癥狀 +時間（Symptom+Time）?癥狀+for+時間如：[Chestpainfor2hours] 胸痛2小時?癥狀+of+時間如：[Nauseaandvomitingofthreedays`duration] 惡心嘔吐3天?癥狀+時間+induration如：[Headache1monthinduration] 頭痛1月?時間+of+癥狀如：[Two-dayhistoryoffever] 發(fā)熱2天2、常見癥狀?[Fever]發(fā)熱?[Pain]疼痛?[Edema]水腫?[Mucocutaneoushemorrhage(bleeding)] 皮膚粘膜出血?[Dyspnea(Difficulyinbreathing;Respiratorydifficulty;shortofbreath)] 呼吸困難?[Coughandexpectoration(Sputumhlegm)] 咳嗽和咯痰?[Hemoptysis] 咯血?[Cyanosis]紫紺?[Palpitation]心悸?[Chestdiscomfort] 胸悶?[Nausea(Retch;DryVomiting)andVomiting] 惡心和嘔吐?[Hematemesis(Vomitingofblood)] 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?[Disturbanceofconsciousness] 意識障礙?[Hematuria]血尿?[Frequentmicturition,urgentmicturitionanddysuria] 尿頻，尿急和尿痛?[Incontinenceofurine] 尿失禁[Retentionofurine]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)熱歡迎下載 2精品文庫?[Dehydration(Inanition)fever] 脫水熱[Drugfever]藥物熱[Functionalhypothermia]功能性低熱[Absorptionfever]吸收熱[Centralfever]中樞性發(fā)熱[Fevertype]熱型[Continuousfever]稽留熱[Remittentfever]馳張熱[Intermittentfever]間歇熱[Undulantfever]波狀熱[Recurrentfever]回歸熱[Periodicfever]周期熱[Irregularfever]不規(guī)則熱[Ephemeralfever]短暫熱?[Doublepeakedfever] 雙峰熱?[Feverofundetermined(unknown)origin,FUO] 不明原因發(fā)熱?[Rigor(shivering;chill;shakingchill;ague)] 寒戰(zhàn)?[ChillySensation(Fellchilly;cold fits;coldness)] 畏寒?[Ultra-hyperpyrexia] 超高熱?[Hyperthermia(Ahighfever;hyperpyrexia;ardentfever)] 高熱?[Moderatefever] 中度發(fā)熱?[Hypothermia(Low-gradefever;slightfever;subfebriletemperature)] 低熱?[Becomefeverish(Haveatemperature)] 發(fā)熱?[Crisis]驟降?[Lysis]漸降?[Typhoidfever] 傷寒熱?[Rheumaticfever] 風(fēng)濕熱?[Cancerousfever] 癌性發(fā)熱?[Fervescenceperiod] 升熱期?[Defervescenceperiod] 退熱期?[Persistentfebrileperiod] 持續(xù)發(fā)熱期（2）疼痛的表示方法?[Backache(Backpain)] 背痛[Lumbago]腰痛[Headache]頭痛[Vasomotorheadache]血管舒縮性頭痛?[Post-traumaticheadache] 創(chuàng)傷后頭痛?[Migraineheadache] 偏頭痛[Clusterheadache]叢集性頭痛[Chestpain]胸痛[Precardialpain]心前區(qū)痛[Retrosternalpain]胸骨后痛?[Abdominalpain(Stomachache)] 腹痛?[Acrodynia(paininlimbs)] 肢體痛歡迎下載 3精品文庫?[Arthrodynia(Arthralgia)] 關(guān)節(jié)痛[Dullpain]鈍痛[Sharppain]銳痛[Twingepain]刺痛?[Knife-likepain(Piercingpain)] 刀割（刺）樣痛[Achingpain]酸痛[Burningpain]燒灼痛?[Colicky(Griping;cramp)pain] 絞痛[Colic]絞痛[Burstingpain]脹痛（撕裂痛）[Hungerpain]饑餓痛[Ticpain]抽搐痛[Bearing-downpain]墜痛[Shock-likepain]電擊樣痛[Jumpingpain]反跳痛[Tendernesspain]觸痛（壓痛）[Girdle-likepain]束帶樣痛[Wanderingpain]游走性痛[Throbbingpain]搏動性痛[Radiatingpain]放射性痛[Crampingpain]痙攣性痛[Boringpain]鉆痛[Intensepain]劇痛[Writhingpain]痛得打滾[Draggingpain]牽引痛[Laborpain]陣痛[Cancerouspain]癌性疼痛[Referredpain]牽涉痛?[Persistentpain(Unremittingpain)] 持續(xù)性痛[Constantpain]經(jīng)常性痛[Intermittentpain]間歇性痛（3）水腫的表示方法[Mucousedema(Myxedema)]粘液性水腫?[Cardiac(Cardiogenic)edema] 心源性水腫?[Nephrotic(renal)edema] 腎源性水腫?[Hepaticedema] 肝源性水腫?[Alimentary(Nutritional)edema] 營養(yǎng)不良性水腫[Angioneuroticedema]血管神經(jīng)性水腫[Pitting]凹陷性[Nonpitting]非凹陷性?[Localized(Local)edema] 局限性水腫?[Generalizededema(Anasarca)] 全身性水腫[Hydrops]積水[Elephantiasiccrus]橡皮腫歡迎下載 4精品文庫?[Cerebral(Brain)edema] 腦水腫?[Pulmonaryedema(Hydropneumonia0] 肺水腫?[Hydrocephalus] 腦積水?[Edemaofendoscrinopathy] 內(nèi)分泌病性水腫?[Invisible(Recessive)edema] 隱性水腫[Frankedema]顯性水腫[Inflammatoryedema]炎性水腫[Idiopathicedema]特發(fā)性水腫[Cyclicaledema]周期性水腫?[Ascites(Abdominaleffusion;hydroperiotoneum)] 腹水?[Pleuraleffusion(Hydrothorax)] 胸水?[Pericardialeffusion(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?[Cardiacdyspnea] 心原性呼吸困難?[Inspiratory]吸氣性?[Expiratory]呼氣性?[Mixed]混合性?[Obstructive] 梗阻性?[Dyspneaatrest] 靜息時呼吸困難?[Dyspneaonexertion] 活動時呼吸困難?[Dyspneaonlyingdown] 躺下時呼吸困難?[Paroxysmalnocturnaldyspnea,PND] 夜間陣發(fā)性呼吸困難[Orthopnea]端坐呼吸[Asthma]哮喘[Cardiacasthma]心源性哮喘[Bronchialasthma]支氣管性哮喘[Hyperpnea]呼吸深快[Periodicbreathing]周期性呼吸?[Tachypnea(Rapidorfastbreath ing;acceleratedbreathing;shortofbreath)] 氣促?[Bradypnea(Slowbreathing)] 呼吸緩慢[Irregularbreathing]不規(guī)則呼吸（5）皮膚粘膜出血的表示方法?[Bleedingspotsintheskin] 皮膚出血點[Petechia]瘀點[Eccymosis]瘀斑[Purpura]紫癜[Splinterhemorrhage]片狀出血?[Oozingoftheblood(Errhysis)] 滲血歡迎下載 5精品文庫?[Bloodblister(Hemophysallis)] 血皰?[Hemorrhinia(Nasalbleeding)] 鼻衄?[Ecchymoma] 皮下血腫（6）咳嗽與咯痰的表示方法?[Drycough(Nonproductivecough;hackingcough)] 干咳?[Sharpcough] 劇咳?[Wetcough(Moistcough)] 濕咳[Productivecough(Loosecough)]排痰性咳[Chroniccough]慢性咳嗽[Irritablecough]刺激性咳嗽[Paroxysmalcough]發(fā)作性（陣發(fā)性）咳嗽[Coughcontinually]持續(xù)性咳嗽[Spasmodiccough]痙攣性咳嗽[Whoopingcough]百日咳[Wintercough]冬季咳[Wheezingcough]喘咳[Shortcough]短咳[Distressedcough]難咳[Shallowcough]淺咳[Droplet]飛沫[Frothysputum]泡沫樣痰[Bloodysputum]血痰?[Mucous(Mucoid)sputum] 粘液樣痰[Purulentsputum]膿痰[Mucopurulentsputum]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?[Chocolatecolouredsputum] 巧克力色痰[Thicksputum]濃痰[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）內(nèi)臟出血的表示方法[Goldstein’shemoptysis]戈耳斯坦氏咯血[Massivehematemesis]大量嘔血?[Epistasis(Nosebleed;Nasalbleeding;Hemorrhinia;rhinorrhagia )]鼻衄[Hematuria]血尿[Initialhematuria]初血尿[Idiopathichematuria]特發(fā)性血尿[Painlesshematuria]無痛性血尿歡迎下載 6精品文庫?[Terminalhematuria] 終末性血尿?[Gross(Macroscopic)hematuria] 肉眼血尿?[Microscopichematuria] 鏡下血尿?[Hematuriainthewholeprocessofurination] 全程血尿?[Gingivalbleeding(Ulaemorrhagia;gumbleeding)] 牙齦出血[Hematochezia]便血[Bloodystool]血便?[Blackstool(Melena)] 黑便?[Tarrystool]柏油樣便?[Bleedingfollowingtrauma] 外傷后出血[Spontaneousbleeding]自發(fā)性出血[BleedingContinuously]持續(xù)出血[Occultblood,OB]隱血[Hematobilia]膽道出血[Hemathorax]血胸[Hemarthrosis]關(guān)節(jié)積血[Hematocoelia]腹腔積血[Hematoma]血腫[Hemopericardium]心包積血[Cerebralhemorrhage]腦出血?[Subarachnoidhemorrhage(SAH)] 蛛網(wǎng)膜下腔出血?[Excessive(Heavy)menstrualflowwithpassage ofclots] 月經(jīng)量多伴血塊?[Mild(Moderate)menses] 月經(jīng)量少（中等）?[PainlessVaginalbleeding] 無痛性陰道出血[Postcoitalbleeding]性交后出血[Pulsatingbleeding]搏動性出血?[Post-operationwoundhemorrhage] 術(shù)后傷口出血?[Excessivebleedingafterdenalextraction] 拔牙后出血過多（8）紫紺的表示方法[Congenitalcyanosis]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[Feelnauseated]惡心感[Postprandialnausea]飯后惡心[Hiccup]呃逆[Sourregurgitation]返酸?[Fecal(Stercoraceous)vomiting] 吐糞?[undigestedfoodVomiting] 吐不消化食物?[BiliousVomiting] 吐膽汁歡迎下載 7精品文庫（10）腹瀉與便秘的表示方法[Moningdiarrhea]晨瀉[Watery(Liquid)diarrhea]水瀉[Mucousdiarrhea]粘液瀉[Fattydiarrhea]脂肪瀉[Chronic(Acute)]慢性（急性）[Milddiarrhea]輕度腹瀉?[Intractable(Uncontrolled)diarrhea] 難治性腹瀉[Protracteddiarrhea]遷延性腹瀉[Bloodystool]血梗[Frothystool]泡沫樣便[Formless(Formed)stool]不成形（成形）便[Loose(Hard)stool]稀（硬）便[Rice-waterstool]米泔樣便[Undigestedstool]不消化便[Dysentericdiarrhea]痢疾樣腹瀉[Inflammatorydiarrhea]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[Pancreaticdiarrhea]胰性腹瀉[Tenesmus]里急后重?[Passastool(Haveapassage;openorrelaxthebowel)] 解大便?[Haveacallofnature] 便意?[Fecalincontinence(Copracrasia)] 大便失禁?[Functionalconstipation] 功能性便秘?[Organicconstipation] 器質(zhì)性便秘?[Habitualconstipation] 習(xí)慣性便秘?[Haveatendencytobeconstipated] 便秘傾向（11）黃疸的表示方法?[Latent(occult)jaundice] 隱性黃疸[Clinicaljaundice]顯性黃疸[Nuclearicterus]核黃疸[Physiologicicterus]生理性黃疸[Icterussimplex]傳染性黃疸[Toxemicicterus]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]血源性歡迎下載 8精品文庫[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[Emictioninterruption]排尿中斷?[Interruptionofurinarystream] 尿線中斷[Nocturia]夜尿[Oliguria]少尿[Polyuria]多尿?[Passwater(Makewater;urinate;micturition)] 排尿[Frequentmicturition(Frequencyofmicturition;fruquenturination;Pollakiuria)]尿頻?[Urgentmicturition(Urgencyofurinationormicturition)] 尿急?[Urodynia(Painonmicturition;painfulmicturition;alginuresis;micturitionpain)] 尿痛?[Dysuria(Difficultyinmicturition;disturbanceofmicturition)] 排尿困難?[Smallurinarystream] 尿線細小?[Voidwithagoodstream] 排尿通暢?[Guttateemiction(Dribblingfollowingurination;terminaldribbling)] 滴尿?[Bifurcationofurination] 尿流分叉?[Residualurine] 殘余尿?[Extravasationofurine] 尿外滲[Stressincontinence]壓力性尿失禁[Overflowincontinence]溢出性尿失禁?[Paradoxicalincontinence] 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?[Nightsweating] 盜汗?[Sweat(Perspiration)]出汗?[Coldsweat]冷汗?[Pruritus(Iching)] 搔癢?[Asthma]氣喘?[Squeezing(Tightness;choking;pressing)sensationofthechest] 胸部緊縮歡迎下載 9精品文庫（壓榨）感?[Intermittentclaudication] 間歇性跛行?[Difficultyinswallowing(Dysphagia;difficultswallowing;acataposi s)]吞咽困難?[Epigastric(Upperabdominal)discomfort] 上腹部不適?[Anorexia(Sitophobia)] 厭食?[Poorappetite(Lossofappetite)] 納差?[Heart-burn(Pyrosis)] 胃灼熱?[Stomachache(Paininstomach)] 胃部痛[Periumbilialpain]臍周痛[Belching(Eructation)]噯氣[Sourregurgitation]返酸?[Abdominaldistention(bloating)] 腹脹?[Passgas(Breakwink)] 肛門排氣[Small(Large)stool]大便少（多）[Expel(Pass)worms]排蟲?[Painovertheliver] 肝區(qū)痛?[Lumbago]腰痛?[Pica(Parorexia;allotriophagy)] 異食癖?[Dysmenorrhea] 痛經(jīng)?[Menoxenia(Irregularmenstruation)] 月經(jīng)不調(diào)?[Polymenorrhea(Epimenorrhea)] 月經(jīng)過頻?[Oligomenorrhea] 月經(jīng)過少?[Excessivemenstruation(Menorrhagia;menometrorrhagia;hypermenorrhea)] 經(jīng)量過多?[Hypomenorrhea(Scantymenstruation)] 經(jīng)量過少?[Menopause(Menostasia;menostasis )]絕經(jīng)?[Amenorrhea(Menoschesis)] 閉經(jīng)?[Leukorrhagia] 白帶過多?[Asexuality(lackoflibido)] 無性欲[Hyposexuality]性欲低下[Hypersexuality]性欲亢進?[Prospermia(Ejaculatiopraecox)] 早泄?[Impotency(impotence)]陽萎?[Nocturnalemission(Spermatorrhea)]遺精?[Lackofpotency]無性交能力?[Hairloss]脫發(fā)?[Jointpain(Arthralgia;arthrodynia)]關(guān)節(jié)痛?[Polydipsia(Excessivethirst)] 多飲（煩渴）?[Polyphagia(Excessiveappetite;hyperorexia;bulimia)] 多食?[Cold(Heat)intolerance] 怕冷（熱）?[Dwarfism(Excessiveheight)] 身材矮?。ǜ叽螅Excessivesweating]多汗[Handstremble]手抖[Obesity(Fatty)]肥胖?[Agitation(Anxiety;nervousirritability)] 焦慮（憂慮）歡迎下載 10精品文庫[Mania]躁狂[Hallucination]幻覺[Aphasia(Logopathy)]失語?[Amnesia(Poormemorization;memorydeterioration)] 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(Poorsleepness;sleeplessness)] 失眠[Nightmare]多夢[Numbness]麻木?[Paininlimbs(Acrodynia)] 肢體痛[Limitationofmotion]活動受限[Tetany]手足抽搐[Dischargeofpus]流膿?[Blurredvision(Hazyvision;blurringofvision;dimnessofvision)] 視物模糊?[Burning(Dry)sensation] 燒灼（干燥）感?[Tearing(Dacryorrhea;Lacrimation)] 流淚?[Doublevision(Diplopia)] 復(fù)視?[Strabismus]斜視?[Hemianopia] 偏盲?[Tiredeyes(Eyestrain)] 眼疲勞?[Foreignbodysensation] 異物感?[Losethesight(Loseofvision)] 失明?[Diminutionofvision] 視力減退?[Nictition]眨眼?[Ophthalmodynia(Eye-ache;ocularpain)] 眼痛[Photophobia]畏光[Spotsbeforetheeyes]眼前黑點[Deafness(Anacusia)]耳聾[Auditorydysesthesia]聽力減退?[Otalgia(Otodynia;painintheear;ear -ache)] 耳痛?[Stuffyfeelingintheear] 耳閉氣[Tinnitus]耳鳴[Outophony]自聲過強?[Nasalobstruction(blockage)] 鼻塞?[Drynessofthenose] 鼻干燥?[Rhinorrhea(Snivel;Nasaldischarge)] 流鼻涕[Sneezing]打噴嚏[Snoring]打鼾?[Hyposmia(Reductionofthesenseofsmell)] 嗅覺減退歡迎下載 11精品文庫?[Anosmia(Completelossofsenseofsmell)] 嗅覺喪失[Dysphonia]發(fā)音困難[Hoarseness]聲嘶?[Painonswallowing] 吞咽痛?[Salivadribbliesfromthemouth] 流涎[Troatyvoice]聲音沙啞[Stridor]喘鳴[Redandswollen]紅腫[Scurf]頭皮屑[Show]見紅?[Amnioticfluidescaped] 破水[Uterinecontraction]宮縮[Acalculia]計算不能[Apathy]情感淡漠[Delusion]妄想第三部分 現(xiàn)病史[Historyofpresentillness(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(jīng)過；四、目前的一般情況。1、誘因?無誘因下[Withnoinducingfactors]?無明顯誘因下[Undernoobviouspredisposingcauses]?感冒一周后[Aftergetting(catching)commoncoldfor1week]2、癥狀出現(xiàn)的敘述?有 癥狀?sufferfrom?haveanattackof?have(fell)?begintofell?afeeling(sensation)of?complain(of)? sensation(feeling)in(of)[發(fā)熱]haveatemperature(becomefeverish)?在情況下發(fā)生活動時呼吸困難[dyspneaonexertion]躺下后即出現(xiàn)咳嗽[Coughoccurssoonafterlying]?與有（無）關(guān)與有關(guān)[beassociatedwith]與有關(guān)[have(make)relationto]與無關(guān)[have(make)norelationto]?在 情況下加重（減輕）歡迎下載 12精品文庫餐后加重[becomeworseaftertakingmeals]站立后緩解[berelievedbystandingup]隨呼吸和咳嗽而加重[becomemoreseverewithbreathingandcough]?伴有beaccompaniedby3、起病方式?急性腹痛[acuteabdominalpain]?慢性低熱[chroniclowerfever]?暴發(fā)性發(fā)病[theonsetwasfulminating]?驟起胸痛[anexplosiveonsetofchestpain]?突然起病伴高熱[theonsetwassuddenwithhighfever]?突發(fā)突止[attacksbeganandendedabruptly]?因 而突然起病[theattackisprecipitated by]?很快發(fā)生暈厥[syncopeoccuredrapidly]?逐漸出現(xiàn)咳嗽咳痰[gradualonsetofcoughandsputum]?偶而[occasionally(sporadically,accidentally)]?反復(fù)胸悶心悸[recurrent(boutsof)chestdiscomfortandpalpitation]?一過性發(fā)作[transitoryattack]?連續(xù)胸痛[chestpaincontinually]?時重時輕[wanedandwaxed]?時好時壞[hanginthebalance]?不停地咳嗽[haveafitofcough]?發(fā)作性呼吸困難[paroxysmalshortofbreath]?頻繁咳嗽[coughfrequently(veryoften)]?持續(xù)性（間歇性）[persistent(intermittent)]?頻發(fā)胸痛[frequentepisodesofchestpain]?持續(xù)不變[besteady]4、病情變化描述?[癥狀好轉(zhuǎn)]?fellbetterthanbefore?takeafavorableturn?takeaturnforthebetter?improve?makefavorableprogress?turnforthebetter?changeforthebetter?bebetter?[癥狀減輕]?alleviate?reduce?palliate?diminish?ease(lighten)?mitigate?[癥狀消失]?disappear歡迎下載 13精品文庫?subside?regress?clearup?vanish?dissolve?die(fade)away?relieve?[ ]?be(make,become,get)worse?worsen?becomemoresevere?takeaturnfortheworse?beaggravated?increaseinseverity?takeabadturn?make(become)moreserious?make(become)heavier?[ ]?remainthesameas?continuewithoutchange?beidentical?bealike?besimilar?resemble?[ ]?waneandwax?hanginthebalance?[ / ][rise(Goup)to][haverisen(goneup)to]? [goupfrom to][beelevatedto][fall(decline,abate)abruptly][suddendrop(elevation)][fall(elevate)gradually][slowcrisis(lysis)of][be(become)lowerdaybyday][begintoremit][drop(wasreduced)tonormal][havegonedown(dropped)to][return(revert)tonormal]? [fall(elevate)from to]? [maintainatalevelof ]? [stabilizeat ]? [feverdisappeared]? [donotgoupover(exceed) ]? [fluctuate(vary)between歡迎下載 14精品文庫and][rangefromto]? 38.5 [anaveragetemperatureof38.5 ]? 39.2 [havefever(atemperature)of39.2 ]5? ?lastedfor2days?havegoneonfor1month?havecontinuedfor10hours?lastedontheaverage3-5hours?lastedavariabletimefrom5minutestoseveralhours?lastedabouthalfanhour? [movethan(lessthan)]? [twoyearsago]? [usuallybetween3and5PM]? [befreeofonsets(attacks)for2weeks]6? [mild(slight)]? [moderate]? [severe(serious)]7?[ ]?belocated(situated)in(over)[ ]?Thereislocalizedpainin []?near[ ]?belocalizedto(in,over)[ ]?belimited(confined)to[ ]?[ ]? [attheapex]? [intheupperabdomen]? [on(beneath)theleftlowerlimb]? [overtherightlung]? [above(below)themouth]? [undertheskinoftheleftbreast]?[ / ]? [shift(migrate)to ]? [radiate(travel,go,refer)to ]? [radiatefrom to]?[ ]? [otalgia(painofears)]? [tinnitus(earsring)]? [abuzzing(ringing,singing)intheears]? [abuzzingsensationintheleftear]? [deafness(lossinhearing)]歡迎下載 15精品文庫?左耳聾[bedeafoftheleftear]?耳流膿[otorrhea(otopyorrhea)]?耳出血[otorrhagia]?耳垢[cerumen(earwax)]?耳血腫[othematoma]?鼻塞[nasalobstruction]?不能用鼻呼吸[beunabletobreathethrough(by)thenose(nasaldyspnea)]?打噴涕和流涕[sneezingandnasaldischarge]?水樣鼻涕[wateryrhinorrhea]?鼻出血[nosebleed]?咽喉痛[sorethroat]?口吃[stuttering]?口臭[ozostomia(saburra,halitosis)]?張口困難[difficult(inability)toopenthemouth]?張口（吞咽、嚼）困難[difficultinopeningthemouth(swallowing，masticating)]?咽下困難[dysphagia]?流涎多[haveexcessivesalvation]?[眼科及牙科癥狀]?眼瞼浮腫[eyelidedema]?眼痛[painintheeyes]?視邊模糊[blurringofvision(blurredvision)]?過度流淚[excessivetearing(watering)]?視疲勞[asthenopia(visionaltired)]?視力減退[hypopsia(diminutionofvision)]?視力衰弱[ophthalmocopia]?遠（近）視力模糊[indistinctdistant(near)vision]?失明[lossofvision]?搏動性牙痛[throbbingpainoftooth(odontalgia)]?牙齦出血[gingivalbleeding]?牙齦萎縮（增生）[gingivalatrophy(hypertrophy)]?牙周溢膿[peripyema]?[婦產(chǎn)科癥狀]?月經(jīng)過多[excessivemenstrualflow(menorrhagia)]?月經(jīng)多并伴血塊[experiencemenorrhagiawithpassageofclots]?經(jīng)量少（中等、多）[mild(moderate,heavy)menses]?月經(jīng)過少[hypomenorrhea]?陰道出血[vaginalbleeding(colporrhagia)]?陰道大出血[massive(profuse)vaginalbleeding]?無痛性（性交后）陰道出血 [painless(postcoital)vaginalbleeding]?陰道干燥[colpoxerosis]歡迎下載 16精品文庫?月經(jīng)規(guī)則（不規(guī)則）[rugular(irregular)menstrualcycle]?月經(jīng)周期26天，持續(xù)4天[menstrualperiodsof26daysandlasted4days]?白帶增多[leukorrhagia(profuseleukorrheaorwhites)]?外陰搔癢[pruritusofvulva]?外陰濕疹（白斑）[eczema(leukoplakia)ofvulva]?絕經(jīng)[amenorrhea]?停經(jīng)[menopause]?停經(jīng)3年[3yearspostmenopausal]?50歲停經(jīng)[Passedmenopauseatage50]?經(jīng)前（期）痛[painbefore(during)theflow]?預(yù)產(chǎn)期[expecteddateofconfinement]?見紅和破水[showandamnioticfluidescaped(ruptureofmembranes)]?羊水過多（少）[polyhydramnios(oligohydramnios)]?月經(jīng)期水腫[menstrualedema]?月經(jīng)失調(diào)[menstrualdisorder]?性欲正常（減退）[normal(decreased)libido]?無性欲[lossoflibido]?性功能障礙[sexualdisorder]?性變態(tài)[paraphilia]?性要求高（低）[beoversexed(undersexed)]?性感不快[dypareunia]?性欲亢進（減退）[hypersexuality(hyposexuality)]?產(chǎn)程[stageoflabor]?產(chǎn)程延長[prolongedlabor]?產(chǎn)道裂傷（損傷）[laceration(injury)ofbirthcanal]?產(chǎn)后腹痛（出血，尿潴留，子癇） [postpartumtormina(hemorrhage,retentionofurine,eclampsia)]?產(chǎn)前出血[antepartumhemorrhage]?產(chǎn)前子癇[prenataleclampsia]?產(chǎn)前檢查[prenatalexamination]?產(chǎn)褥熱[puerperalfever]?產(chǎn)褥期護理[pureperalcare]?妊娠嘔吐[vomitingofpregnancy(hyperemesisgravidarum)]?妊娠反應(yīng)[pregnancyreaction]?妊娠高血壓（水腫）[gestationhypertension(edema)]?[病程中的一般情況]?一般情況尚可（一般、差） [generalconditionisfair(ordinary,bad)]?胃納佳（差）[haveagood(poor)appetite]?過度進食[eattoomuch(overeat,eatheavily)]?過少進食[eatpoorly(takelittlefood)]?無食欲[havenoappetite]?食欲減退[appetitedecreases]歡迎下載 17精品文庫?口渴[feelthirsty]?大量飲水[drinkwatergenerously]?體重增加[gaininweight]?體重增加8公斤[a8kilogramsweightgain(gain8kilograms)]?體重減輕[lossofweight(weightloss)]?體重穩(wěn)定不變[bodyweightisstable(unchanged,maintained)]?睡眠障礙[somnipathy]?睡眠不足[lack(want)ofsleep]?不易入睡[havetroublegettingtosleep]?容易入睡[fallintoasleepveryeasily]?睡眠過度[hypersomnia]?睡行癥[sleepwalking]?嗜（貪）睡[somnolence(befondofsleep)]?夜晚因 而易醒[easilywakenedatnightbecauseof ]?失眠[haveinsomnia]?睡眠差（好）[sleepispoor(good)]?消化不良[dyspepsia(havebaddigestion)]?大（?。┍阃〞砙stool(urination)iseasyandsmooth(unobstructed,clear)]?每日2次大便[havetwostoolsdaily]?含粘液的水樣便[waterystoolscoutainingmucus]?便秘（腹瀉）[constipation(diarrhea)]?排尿困難[difficultyinmicturition]?尿頻（急）[frequency(urgency)ofmicturition]?尿痛[micturitionpain]?少尿（無尿、多尿）[oliguria(anuria,polyuria)]?大便失禁[fecalincontinence]?小便失禁[incontinenceofurine]?精神不振[lassitude]?精神緊張（抑郁）[mentalstress(depression)]?精神混亂[confusion]?精神失常[amentia(mentalstateisbad)]?精神狀態(tài)正常[orthophrenia(mentalstateisgood)]?體力旺盛（不足，正常） [hypersthenia(hyposthenia,euthesia)]第四部分 過去史、系統(tǒng)回顧和個人史（Pasthistory,systemsreviewandpersonalhistory ）1、過去史[pasthistory]?無藥物（食物）過敏史[nopasthistoryofallergytodrugs(food)]?有青霉素過敏史[haveallergichistoryofpencillin]?有肺結(jié)核接觸史[therewascontacthistoyoflungtuberculosis]?2000年6月因急性闌尾切除術(shù)[AppendectomywasdoneinJune,2000duetoacuteappendicitis]?健康狀況佳（差）[healthstatewasgood(bad)]?既往體健[bewell(healthy)before]?否認既往心、肺疾病史[denyanyhistoryofpriorheartandlungdisease]歡迎下載 18精品文庫?10歲時（20年前）曾患過 [sufferedfrom atage10(20yearsago)]?易患 [beliable(subjuct,apt)to ]?不詳[notindetail(notquiteclear)]?外傷史[rtaumahistory]?預(yù)防接種史[historyofpreventiveinoculation]2、系統(tǒng)回顧[systemreview]?呼吸系統(tǒng)：咳嗽、咳痰、呼吸困難、胸痛、盜汗、發(fā)熱[respiratorysystem:cough,sputum,shortofbreath,chestpain,nightsweeting,fever.]?循環(huán)系統(tǒng)：心悸、胸痛、氣促、咳嗽和咯血、水腫、暈厥、頭暈[Circulatorysystem:palpitation,chestpain,shortofbreath,coughandhemoptysis,edema,syncope,dizziness.]?消化系統(tǒng)：噯氣、返酸、腹脹、腹痛、腹瀉、惡心和嘔吐[alimentarysystem:belching,sourregurgitation,abdominaldistension,abd.pain,diarrhea,nauseaandvomiting.]?泌尿系統(tǒng)：排尿困難、尿頻和尿急、尿痛、腹痛、水腫 [urinarysystem:difficultyinmicturition,frequencyandrugencyofmicturition,painfulmicturition,abdominalpain,edema.]?造血系統(tǒng)：乏力、頭暈、心悸、出血 [hematopoieticsystem:fatigue,dizziness,palpitation,bleeding.]?內(nèi)分泌系統(tǒng)：心悸、怕熱、多汗、煩渴、水腫、手抖、消瘦和肥胖[endocrinesystem:palpitation,heatintolerance,excessivesweeting,polydipsia,edema,handtremble,wastingandobesity.]?神經(jīng)系統(tǒng)：頭痛、暈厥、頭暈和眩暈、失眠、偏癱、失語[nervoussystem:headache,coma,dizzinessandvertigo,insomnia,hemiplegia,aphasia.]?運動系統(tǒng)：關(guān)節(jié)痛、麻木、跛行、癱瘓 [motorsystem:jointpain,numbness,claudication,paralysis.]3、個人史[personalhistory]?出生于（出生地）[wasbornin(birthplace)]?出生后一直生活[havelivedin (the)rsincebirth]?曾（未曾）去過北方[have(denyhaving)beentothenorth]?受教育程度（文盲、小學(xué)、中學(xué)、大學(xué)） [educationallevel(illiterate,primary,middle,highgrade)]?業(yè)余愛好[hobby(befondof,bekeenof,interest)]?從事 職業(yè)[beengagedin]?衛(wèi)生習(xí)慣和嗜好[healthhabitandspecialaddiction]?不潔性交（性行為）史[historyofuncleancoitus(sexualbehavior)]?不吸煙[nosmoking(notasmoker)]?吸煙20年，每天2包[havesmokedtwopackageso