常用臨床醫(yī)學(xué)術(shù)語

PAGE6簡明病歷書寫手冊(cè)（英漢對(duì)照）郭航遠(yuǎn)編著目錄第一章 病人身份第二章 主訴第三章 現(xiàn)病史第四章 過去史、系統(tǒng)回統(tǒng)和個(gè)人史第五章 月經(jīng)、婚姻、生育史和家族史第六章 體檢（一般項(xiàng)目）第七章 體檢（頭頸部）第八章 體檢（胸腹部）第九章 體檢（神經(jīng)、骨骼和肌肉）第十章 體檢（泌尿生殖道與其他）第十一章 標(biāo)準(zhǔn)化病人體檢項(xiàng)目第十二章 實(shí)驗(yàn)室檢查第十三章 輔助檢查第十四章 診斷（疾病名稱）第十五章 常用醫(yī)囑術(shù)語第十六章 常用藥物及中草藥第十七章 住院文書格式第十八章 附錄附1、常用解剖術(shù)語附2、醫(yī)學(xué)英語常用前后綴附3、醫(yī)學(xué)英語的特征附4、醫(yī)學(xué)英語常用短語附5、英語問診常用句子附6、醫(yī)學(xué)英語縮寫一覽表附7、醫(yī)院日常用品和設(shè)備附8、醫(yī)學(xué)院和醫(yī)院相關(guān)名稱前言隨著我國加入WTO，醫(yī)療體制發(fā)生了革命性的改變。隨著改革開放的深入，外國投資和管理的醫(yī)院將不斷涌現(xiàn)，中外醫(yī)學(xué)交流也日趨頻繁，出國學(xué)習(xí)、進(jìn)修和援外醫(yī)療隊(duì)的醫(yī)務(wù)人員逐年增多，這就要求醫(yī)生具有正確書寫英文病歷的能力。目前，國內(nèi)供臨床醫(yī)生完成英文病歷的參考書很少。簽于此，編著者根據(jù)美國羅馬琳達(dá)大學(xué)的病歷書寫要求，結(jié)合十余年的國內(nèi)外工作經(jīng)驗(yàn)（編者所在的邵逸夫醫(yī)院是一所由美國專家管理的、與國際接軌的新型綜合性醫(yī)院，有十余年的英文病歷書寫實(shí)踐），并參閱一些國內(nèi)外的相關(guān)文獻(xiàn)，編寫了本手冊(cè)。本手冊(cè)按病歷書寫的順序進(jìn)行編寫，采用英中對(duì)照寫法，內(nèi)容詳盡，條理清晰，形式新穎，適用于臨床醫(yī)生、出國人員、實(shí)習(xí)生和醫(yī)學(xué)院校的學(xué)生。在本手冊(cè)的編寫過程中，得到了美國羅馬琳達(dá)大學(xué)醫(yī)學(xué)院和日本福井大學(xué)醫(yī)學(xué)院和邵逸夫醫(yī)院領(lǐng)導(dǎo)的關(guān)心和支持。謹(jǐn)以此書獻(xiàn)給我的老師、同事、朋友和家人。第一章病人身份[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(hào)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(fèi)用·[Typeofadmission(Patientcondition)]住院類別（入院時(shí)病情）·[MedicalrecordNo.]病歷號(hào)·[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(hù)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(fèi)用的表示方法·[Selfpay(Individualmedicalcare)]自費(fèi)·[Governmentinsruance(Publicmedicalcare)]公費(fèi)·[Insurance]保險(xiǎn)·[Localinsurance]本地醫(yī)?！Non-localinsurance]外地醫(yī)?！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·浙·[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(jī)·[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)·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(shí)病情的表示方法·[Stable]穩(wěn)定·[Unstable]不穩(wěn)定·[Relativestable]相對(duì)穩(wěn)定·[Critical(Imminent)]危重·[Fair(General)]一般第二章主訴[ChiefComplaint]1、主訴的表示方法：癥狀+時(shí)間（Symptom+Time）·癥狀+for+時(shí)間如：[Chestpainfor2hours]胸痛2小時(shí)·癥狀+of+時(shí)間如：[Nauseaandvomitingofthreedays`duration]惡心嘔吐3天·癥狀+時(shí)間+induration如：[Headache1monthinduration]頭痛1月·時(shí)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(Sputum;Phlegm)]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(shí)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·[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;coldfits;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·[Ophthalmodynia(Eye-ache;ocularpain)]眼痛·[Photophobia]畏光·[Spotsbeforetheeyes]眼前黑點(diǎn)·[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(qiáng)·[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·[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(jì)算不能·[Apathy]情感淡漠·[Delusion]妄想4、時(shí)間的表示方法（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·[Oneyear(day)]1年（天）·[Twoyears(days)]2年（天）·[Wholeyear]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[Thedaybdforeyesterday]·后天[Thedayaftertomorrow]·大前天[3daysago]·大后天[3dayshence]·今晚[Tonight]·昨晚[Lastnight]·明晚[Nextnight]·通宵[Allnight]·整天[Allday(thewholeday)]（4）季節(jié)[Season]和時(shí)節(jié)[Solarterms]·春季[Spring]·夏季[Summer]·秋季[Autumn]·冬季[Winter]·立春（夏、秋、冬）[theBeginningofSpiring(Summer;Autumn;Winter)]·小暑（雪、寒）[SlightHeat(Snow;Cold)]·大暑（雪、寒）[GreatHeat(Snow;Cold)]·雨水[RainWater]·驚蟄[theWakingofInsects]·春（秋）分[theSpiring(Autumnal)Equinox]·清明[PureBrightness]·谷雨[GrainRain]·小滿[GrainFull]·芒種[GraininEar]·夏（冬至）[theSummer(Winter)Solstice]·處暑[theLimitofHeat]·白（寒）露[White(Cold)Dew]·霜降[Frost’sDescent]（5）時(shí)間的表示方法·In[在……內(nèi)（后）]▲在2003年[In2003]▲在3月[InMarch(Mar.)]▲在去年10月[InlastOct.]▲在早晨[Inthemorning]▲在上午[Intheforenoon]▲在下午[Intheafternoon]▲在晚上[Intheevening]▲在近5天[Inthepast5days]▲在10分鐘后[In10minutes]▲在秋季[Inautumn]▲在這2～3天內(nèi)[Inacoupleofdays]·Within[在……中]▲在近8個(gè)月中[Withinthelast8months]▲在過去的2年中[Withinthepreceding2years]·On[在……時(shí)候]▲在2002的9月18日[Onthe18thofSeptember,2002(英國)orOnsept.18th,2002(美國)▲在星期三[OnWednesday]▲在本月7日[On7thinstant]·At[在……時(shí)]▲在中午[Atnoon]▲在晚上[Atnight]▲在昨晚[Atlast(preceding;previous)night]▲在半夜[Atmidnight]▲在上午10點(diǎn)鐘[At10AM]▲在5歲時(shí)[Attheageoffive]▲在2000年底（中、初）[Attheend(middle;beginning)of2000]·For[計(jì)……時(shí)間]

▲一周[Foroneweek]▲近2個(gè)月來[Forthepast2months]▲幾乎（整整）一年[Fornearlyamonth(afullmonth)]▲3個(gè)月左右[For3monthsorso]▲至少3個(gè)月[Foratleast3months]▲3個(gè)月以上[Formorethan3months]▲3個(gè)月或以上[For3monthsormore]▲時(shí)間不詳[Foranunknown(indefinite)period(time)]·Of[在……時(shí)期]▲10年內(nèi)[Of10years`duration]▲期間[Lengthoftime]▲6月6日[The6thofJune]·Dring[在……期間]▲在2000-2005年的幾年中[Duringtheyearsform2000to2005]▲在這4年中[Duringfouryears]▲在過去的幾周中[Duringthepast(Last)coupleofweeks]▲在夜間[Duringthenight]▲整天[Duringtheentireday]·About[約]▲約1個(gè)半小時(shí)[Aboutoneandhalfanhour]▲大約半年[Abouthalfayear]·To[至；在……之前]▲從今下午點(diǎn)至明上午8點(diǎn)[Form6PMtodayto8AMtomorrow]▲6點(diǎn)45分[Atfifteentoseven]·From[從……起]▲從14歲至52歲[From14to52year-old]▲從上午7點(diǎn)30分開始[Form7:30AM]▲從周一至周五[FromMondaythroughFriday]·Past[過去；超過]▲在過去的3周中[Inthepast3weeks]▲8點(diǎn)10分[tenminutespasteight]·Throughorthroughout[在……整個(gè)期間]▲通宵值班[Beondutythroughthenight]▲從一月到六月[FromJanuarythroughJune]▲熬過明晚[Throughthenextnigut]▲整天（晚）[Throughouttheday(night)]·Over[在……期間]▲在過去的2個(gè)月內(nèi)[Overthepasttwomonths]▲一夜間[Overnight]（6）其他表示方法·每月（年、日）一次[Monthly(Yearly;daily)]·整整一年[Yearlong(Year-round)]·滿周歲[Yearling]·工作日[Weekday]·周末[Weekend]·每周末[Weekends]·8小時(shí)工作日[Aneight-hourday]·整天[Daylong]·白天[Daytime]·晝夜[Nighttime]·日常的[Day-to-day]·夏令時(shí)間[Daylightsavingtime]·每晚[Nightly]·黃昏[Nighfall]·過期的[Overdue]·前天晚上（一夜間）[Overnight]·After[在……之后]▲婚后[Afterone`smarriage]七點(diǎn)十分[Tenafter(past)seven]?。ǔ觯┰汉骩Afteradmission(discharge)]起病后2天[2daysaftertheonset(attack)ofsymptoms]·Before[在……之前]7點(diǎn)50分之前[Beforesevenfifty]醫(yī)生到達(dá)前[Beforethedoctorcome]以前未有種癥狀[Havehadnotthesamesymptombefore]·Ago[以前]5年前[5yearsago]直到一個(gè)月前[Uptoonemonthago]大前天[Threedaysago]·Priorto[在……之前]入（出）院前[Priortoadmission(discharge)]前天之前[Priortothedaybeforeyesterday]·Upto[直到]直到3周前[Upto3weeksago]直到現(xiàn)在（出院）[Uptonow(discharge)]·Untilortill[直到]直到80歲[Until80yearsold]直到今晨8點(diǎn)[Until8o`clockthismoning]直到醫(yī)生查完房[Untilthedoctorhavefinishedthewardround]直到3年以前[Until3yearsago]直到出院前一天[Until1daypriortodischarge]·By[在……之前]下午點(diǎn)鐘前[By5PM]下個(gè)月之前[Bynextmonth]·Since[從……開始]自從去年術(shù)后[Sinceoperationwasperformedlastyear]前天起[Sincethedaybeforeyesterday]從2002年6月起[SinceJune2002]·超時(shí)(加班)[Overtime]·上午8點(diǎn)[8：00AM]·下午2點(diǎn)30分[2：30PM]·7點(diǎn)50分[Sevenfifty(Tentoeight)]·9點(diǎn)20分[Ninetwenty(Twentypastorafternine)]·術(shù)前[Pre-operation]·術(shù)后[Post-operation]第三章現(xiàn)病史[Historyofpresentillness(HPI/PI)]現(xiàn)病史書寫的重點(diǎn)包括：一、主訴中癥狀的詳細(xì)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▲sufferfromhaveanattackofhave(fell)begintofellafeeling(sensation)of……complain(of)……sensation(feeling)in(of)……[發(fā)熱]haveatemperature(becomefeverish)·在……情況下發(fā)生活動(dòng)時(shí)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）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[theattackisprecipitatedby……]·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(shí)重時(shí)輕[wanedandwaxed]·時(shí)好時(shí)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 ▲subside ▲regress ▲clearup ▲vanish ▲dissolve ▲die(fade)away ▲relieve·[癥狀加重]▲be(make,become,get)worse ▲worsen ▲becomemoresevere ▲takeaturnfortheworse ▲beaggravated ▲increaseinseverity ▲takeabadturn ▲make(become)moreserious ▲make(become)heavier·[無變化] ▲remainthesameas…… ▲continuewithoutchange ▲beidentical ▲bealike ▲besimilar ▲resemble·[時(shí)好時(shí)壞] ▲waneandwax ▲hanginthebalance·[體溫/血壓升降]升至[rise(goup)to]已升至[haverisen(goneup)to]從……升至……[goupfrom……to……]升至[beelevatedto]迅速下降[fall(decline,abate)abruptly]驟降（升）[suddendrop(elevation)]漸降（升）[fall(elevate)gradually]緩慢下降[slowcrisis(lysis)of]一天天下降[be(become)lowerdaybyday]開始降低[begintoremit]降至正常[drop(wasreduced)tonormal]已降至[havegonedown(dropped)to]回復(fù)到正常[return(revert)tonormal]由……降（升）至……[fall(elevate)from……to……]維持在……水平[maintainatalevelof……]穩(wěn)定在……[stabilizeat……]熱退了[feverdisappeared]不超過[donotgoupover(exceed)……]在……和……之間波動(dòng)[fluctuate(vary)between……and……]在……至……范圍內(nèi)[rangefrom……to……]平均38.5℃[anaveragetemperatureof38.5℃]有39.2℃的體溫[havefever(atemperature)of39.2℃]5、癥狀的時(shí)間表示·持續(xù) ▲lastedfor2days ▲havegoneonfor1month ▲havecontinuedfor10hours ▲lastedontheaverage3-5hours ▲lastedavariabletimefrom5minutestoseveralhours ▲lastedabouthalfanhour·超過（不到）[movethan(lessthan)]·……以前[twoyearsago]·多在……時(shí)發(fā)生[usuallybetween3and5PM]·未發(fā)作過[befreeofonsets(attacks)for2weeks]6、癥狀的嚴(yán)重程度·輕度[mild(slight)]·中度[moderate]·重度[severe(serious)]7、癥狀的其他描述方法·[部位] ▲belocated(situated)in(over)[位于] ▲Thereislocalizedpainin……[疼痛位于] ▲near……[在……附近] ▲belocalizedto(in,over)[局限于] ▲belimited(confined)to[局限于]·[表示部位的介詞] ▲心尖部，表示小的部位或點(diǎn)[attheapex] ▲上腹部，表示大的部位[intheupperabdomen] ▲在左下肢，表示皮膚表面上（下）的病變[on(beneath)theleftlowerlimb] ▲在右肺，表示正上方的相應(yīng)體表部位[overtherightlung] ▲嘴上（下）方，表示高低或上下的位置關(guān)系[above(below)themouth]▲左乳皮下[undertheskinoftheleftbreast]·[轉(zhuǎn)移/放射] ▲轉(zhuǎn)移到……[shift(migrate)to……] ▲放射到……[radiate(travel,go,refer)to……] ▲從……放射到……[radiatefrom……to……]·[耳鼻咽喉及口腔癥狀] ▲耳痛[otalgia(painofears)] ▲耳鳴[tinnitus(earsring)] ▲耳鳴[abuzzing(ringing,singing)intheears] ▲左耳有耳鳴感[abuzzingsensationintheleftear] ▲耳聾[deafness(lossinhearing)] ▲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(yuǎn)（近）視力模糊[indistinctdistant(near)vision] ▲失明[lossofvision] ▲搏動(dòng)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] ▲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(jìn)（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(hù)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(jìn)食[eattoomuch(overeat,eatheavily)] ▲過少進(jìn)食[eatpoorly(takelittlefood)] ▲無食欲[havenoappetite] ▲食欲減退[appetitedecreases] ▲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 ▲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)]第四章過去史、系統(tǒng)回顧和個(gè)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(rèn)既往心、肺疾病史[denyanyhistoryofpriorheartandlungdisease]·10歲時(shí)（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(yùn)動(dòng)系統(tǒng)：關(guān)節(jié)痛、麻木、跛行、癱瘓[motorsystem:jointpain,numbness,claudication,paralysis.]3、個(gè)人史[personalhistory]·出生于（出生地）[wasbornin(birthplace)]·出生后一直生活[havelivedin……(there)sincebirth]·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[havesmokedtwopackagesofcigaretteadayfor20years]·戒煙[giveup(stop)smoking]·戒煙[smokingabstinence(withdrawal)]·不飲酒[noalcoholuse]·偶而少量飲酒[drinklittleliquoroccasionally]·過度飲酒[drinkheavily(toomuch)]·每天飲酒0.5公斤[drink(imbibe)about0.5kilogramaday]·酒精性飲料[alcoholicbeverage]·偏食[foodpreference(particularwithfood)]·無偏食[nolikesordislikesinfood]·偏愛……[havepartialityfor(showefavoritismto,bepartialto,like)]第五章月經(jīng)、婚姻、生育史和家族史[Menstrual,marritalandchildbearinghistoryandfamilyhistory]1、月經(jīng)史[menstrualhistory]·初潮年齡[ageofmenarche]·月經(jīng)周期[menstrualcycle]·行經(jīng)期[menstrualperiod]·未次月經(jīng)時(shí)間[lastmenstrualperiod(LMP)]·閉經(jīng)年齡[ageofmenostasis]·白帶過多[profuseleukorrhea(whites)]·月經(jīng)過多[menorrhagia(hypermenorrhea,menometrorrhagia)]·月經(jīng)過少[hypomenorrhea(scantymenstruation)]·月經(jīng)過頻[polymenorrhea]·月經(jīng)稀發(fā)[oligomenorrhea]·月經(jīng)不調(diào)[menoxenia(irregularmenses,menstrualdisorder)]·月經(jīng)正常[eumenorrhea(regularmenses)]·經(jīng)前水腫（疼痛）[premenstrualedema(pain)]·經(jīng)量少（中、大）量[mild(moderate,heavy)meustrualblood]·痛經(jīng)[dysmenorrhea(painduringtheflow)]·36歲就停經(jīng)了[passthemenopauseatage36]2、婚姻史[marritalhistory]·未婚（已婚）[single(married)]·結(jié)婚年齡[ageofwedding]·配偶的健康狀況[healthstatusofpartner(spouse)]·性生活和諧（不和諧）[sexuallifeisharmonious(disorder)]·夫妻關(guān)系和睦（不和睦）[relationofhusbandandwifeisamicable(hostile)]·近親（非近親）結(jié)婚[consanguineous(nonconsanguineous)marriage]3、生育史[childbearinghistory]·妊娠（生育）次數(shù)和年齡[timesandageofpregnancy(childbearing)]·懷孕和生產(chǎn)次數(shù)[pregnanciesandlabors]·人工（自然）流產(chǎn)次數(shù)[timesofinduced(spontaneous)abortion(miscarriage)]·流產(chǎn)[miscarriage(abortion)]·死胎（產(chǎn)）[deadfetus(birth)]·割腹產(chǎn)[caesareanbirth(bebornbycaesareansection)]·子女?dāng)?shù)[numberofchildren]·早產(chǎn)（兒）[prematurebirth(bady)]·足月產(chǎn)[termlabor]·產(chǎn)褥熱（感染）[puerperalfever(infection)]·計(jì)劃生育[familyplanning(birthcontrol)]·用避孕環(huán)（藥、油膏、套、栓）避孕[contraceptionbyintrauterinering(contraceptives,ointment,condom,supposity)]·節(jié)育手術(shù)[contraceptiveoperation]·自然分娩[bedeliverednormallyandspontaneously(spontaneouslabor)]·產(chǎn)鉗分免[forcepsdelivery(bedeliveredbyforceps)·產(chǎn)前（后）子癇[antepartum(postpartum)eclampsia]·出生時(shí)3.5公斤重，48厘米高[3.5kilogramsand48cminheightatbirth]·母乳喂養(yǎng)[breastfeeding(befedatbreast)]·人工喂養(yǎng)[artificialfeeding]·發(fā)育正常[normaldevelopment]·發(fā)育異常(停頓、缺陷、畸形)[developmentalanomaly(arrest,defect,deformity)]·發(fā)育遲緩（過渡）[hypoevolutism(hypergenesis)]4、家庭史[familyhistory]·父母（兄弟，姐妹和兒女）的健康狀況和疾病情況[healthstatusandillnessofparents(brothers,sistersandchildren)]·同樣疾病[thesamesickness]·遺傳疾病[heredopathia(geneticdisease)]·遺傳特征[hereditaryfeature]·死因[causeofdeath]·健康[behealthy(beingoodhealthy)]·健在[belivingandwell]·無……家族史[nofamilyhistoryof……]·死于……[dieof……]第六章體檢（一般項(xiàng)目）[Physicalexamination(generalitems)]·視診[inspection]·觸診[palpation]·叩診[percussion]·聽診[auscultation]·嗅診[olfactoryexamination]·淺（深）觸診法[light(deep)palpation]·深部滑行（深壓，雙手，沖擊）觸診法[deepslipping(deeppress,bimanual,ballottement]·間接（直接）叩診[indirect(direct)percussion]·叩診音（過清音，清音，濁音，鼓音，實(shí)音）[percussionsound(hyperresonance,resonance,dullness,tympany,flatness)]·用鐘（膜）型胸件聽診[withthebell(diaphragmatic)chestpiece]1、體溫[temperature,T]·口（腋、肛）溫[oral(axillary,rectal)temperature]·經(jīng)口（腋、肛）測(cè)的溫度[permouth(axilla,rectum)]·攝氏與華氏換算[CentigradeVSFahrenheit]℃=5/9(℉-32)℉=9/5℃+32℃～℉℃～℉36.5～97.738.5～101.337.0～98.638.9～102.037.2～99.039.0～102.237.5～99.539.4～103.037.8～100 40.0～104.038.0～100.4 40.5～104.938.3～101.0 41.0～105.8·37.5℃.orally(99.5℉)[口溫?cái)z氏37.5度（華氏99.5度）]2、脈搏[pulse,P]·脈率72次/分[pulse72beatsperminute(P72bpm)]·搏動(dòng)存在（消失）[pulsearepresent(absent)]·速（緩）脈[fast(slow)pulse]·洪（細(xì)絲）脈[bounding(small,thready)pulse]·水沖脈[waterhammerpulse]·交替脈[alternatingpulse]·奇脈[paradoxical]·二聯(lián)（三聯(lián)）脈[bigeminal(trigeminal)pulse]·重脈[dicroticpulse]·間歇脈[intermittentpulse]·陷落脈[collapsing]·不規(guī)則（規(guī)則）脈[irregular(regular)pulse]3、呼吸[respiration,R]·呼吸頻率[respiratoryrate(RR)]·呼吸頻率19次/分[RR19beats/min(R19bpm)]·規(guī)則（不規(guī)則）呼吸[regular(irregular)breathing]·呼吸均勻[eupnea]·呼吸急促（緩慢）[repid(slow)breathing]·呼吸停止（中斷）[pausal(interrupted)breathing]·呼吸驟停[breatharrest]·深（淺）呼吸[deep(superficial)breathing]·呼吸困難[dyspna(shortofbreath)]·呼吸費(fèi)力[laboredbreathing]·胸（腹）式呼吸[thoracic(abdominal)breathing]·張口呼吸[mouth(buccal)breathing]·周期性呼吸[periodicrespiration]·庫斯毛氏呼吸[Kussmaul`srespiration]·陳-施（潮式）呼吸[Cheyne-Stokes(tidal)respiration]·間歇呼吸[Biot`sbreathing]·嘆息樣（胎兒,鼾樣）呼吸[sighing(fetal,stertorous)respiration]·口臭[havefoul(fetid)breath(halitosis)]·酮味呼吸[asmellofketone]·靜息下（活動(dòng)時(shí)）氣促[dyspneaatrest(onexertion)]·丙酮（氨臭，蒜臭）味[acetone(ammoniacal,alliaceous)odor]·肝臭[hepaticusfetor]·腋臭[bromidrosis]4、血壓[bloodpressure,BP]·收縮（舒張）壓[systolic(diastolic)bloodpressure]·血壓20/12千帕（150/90毫米汞柱）[BP20/12kPa(150/90mmHg)]1kPa=7.5mmHg(1mmHg=0.1333kPa)·血壓為收縮壓20，舒張壓12千帕[Bpis20over12(Bpis20systolicand12diastolic)]·測(cè)量血壓[take(measure,check)Bp]·坐（臥）位血壓[sitting(lying)Bp]·無創(chuàng)（有創(chuàng)）血壓[non-invasive(invasive)Bp]·脈壓[pulsepressure]·血壓測(cè)不出[Bpisunavailable(unobtained)]·左臂（右臂）血壓[Bpinleft(right)arm]·雙下肢血壓[Bpinbothlowerlimbs]·袖帶[cuff]5、體位[position]·主動(dòng)（被動(dòng)、強(qiáng)迫）體位[active(passive,forced)position]·立（坐、臥）位[upright(sitting,dorsal)position]·仰臥（俯臥）位[supine(prone)position]·左（右）側(cè)臥位[left(right)lateral(decubitus)position]·蜷腿位[coiledposition]·半臥位[semi-reclining(semi-recumbent)position]·端坐位[orthopneaposition]·胸膝（膝肘）位[knee-chest(knee-elbow)position]·截石（分娩）位[dorsosacral(obstetric)position]·角弓反張位[opisthotonusposition]·強(qiáng)迫蹲位[compulsivesquattin]·輾轉(zhuǎn)體位[alternativeposition]·頭高（低）腳低（高）位[high(low)headandlow(high)legs]6、神志和意識(shí)[consciousnessandmind]·清醒（半清醒的）[alert(semi-conscious)]·昏迷（半昏迷）的[comatose(semi-comatose)]·無精打采的[listless]·思睡的[somnolent(drowsy,sleepy)]·昏睡的[lethargic]·焦慮不安的[anxious(restless,apprehensive)]·激動(dòng)的[excited(irritable)]·精神錯(cuò)亂的[confused]·意識(shí)障礙[distrubanceofconsciousness]·譫妄[delirium]·抽搐[convulsion]·木僵的[stuporous]·合作佳（欠佳、差）[cooperationisgood(notgoodenough,bad)]·反應(yīng)遲鈍[haveadullreaction]·有（無）定向力[beoriented(disoriented)]·朦朧狀態(tài)[beinamisttent]·神志模糊[blurred(dim,vague)mind]·失去知覺[lossconsciousness(unconsciousness)]·對(duì)疼痛刺激的反應(yīng)[reactiontopainfulstimuli]7、面容[facialfeatures]·呈急（慢）性面容[beinacute(chronic)distress]·病然面容[criti