第一部分 病人身份[Identification]
• [Name] 姓名
• [Sex] 性别• [Age] 年龄• [Occupation] 职业• [Date of birth] 出生日期• [Marriage （Marital status）] 婚姻• [Race] 民族• [Place of birth (Birth place)] 籍贯• [Identification No.(code of ID card No.)] 身份证号码• [Department of work and TEL. No. (Unit and Business phone No.)] 工作单位及电话• [Home address and phone No.] 家庭住址及电话• [Post code] 邮政编码• [Person to notify (Correspondent) and phone No.] 联系人及电话• [Source (Complainer;offerer;supplier;provider) of history] 病史陈术者• [Reliability of history] 病史可靠程试• [Medical security (Type of payment)] 医疗费用• [Type of admission (Patient condition)] 住院类别（入院时病情）• [Medical record No.] 病历号• [Clinic diagnosis] 门诊诊断
• [Date of admission (admission date)] 入院日期 [Date of record] 记录日期
1、年龄的表示方法（以36岁为例）
•36 years old (y/o)•Age 36•36 year-old•The age of 36
•36 years of age
2、性别的表示方法
• [Male,♂] 男性• [Female,♀] 女性
3、职业的表示方法
•工人[Worker] •退休工作[Retired worker]•农民[Farmer (peasant)] •干部[Leader (cadre)]•行政人员[administrative personnel (staff)]•职员[staff member] •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[Conductor]
4、民族的表示方法
•汉[Han] •回[Hui] •蒙[Meng] •藏[Tibetan]•朝鲜[Korean]•美国人[American] •日本人[Japanese] •英国人[Britisher]
5、医疗费用的表示方法
• [Self pay (Individual medical care)] 自费• [Government insruance (Public medical care)] 公费• [Insurance] 保险
• [Local insurance] 本地医保• [Non-local in surance] 外地医保• [Labor protestion care] 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
• [Not entirely] 不完全可靠
• [Unobtainable] 无法获得
8、住址的表示方法
•[NO.3,Qing Chun Road East,Hangzhou, Zhejiang] 浙江省杭州市庆春东路3号
•[XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.] 浙江省诸暨市（县）城关镇新东村
9、病史陈述者的表示方法
• [Patient himself (herself)] 患者本人• [Her husband] 患者的丈夫• [His wife] 患者的妻子• [Patient`s colleague] 患者的同事
• [Patient`s neighbor] 患者的邻居• [Patient`s Kin (Mother; Son; daughter;brother;Sister)] 患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹)• [Taximan] 出租车司机• [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)](美国)
•2002年10月1日[1-10-2002(1/10/2002; 1 Oct.,2002; 1st of Oct.,2002)] (英国)
11、住院类别的表示方法
• [Emergent (Emergency call)] 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• [Relative stable] 相对稳定• [Critical (Imminent)] 危重• [Fair (General)] 一般
第二部分 主诉[Chief Complaint]
1、主诉的表示方法：症状+时间（Symptom+Time）
•症状+for+时间
如： [Chest pain for 2 hours] 胸痛2小时
•症状+of+时间
如： [Nausea and vomiting of three days` duration] 恶心呕吐3天
•症状+时间+in duration
如： [Headache 1 month in duration] 头痛1月
•时间+of+症状
如： [Two-day history of fever] 发热2天
2、常见症状
• [Fever] 发热
• [Pain] 疼痛
• [Edema] 水肿
• [Mucocutaneous hemorrhage (bleeding)] 皮肤粘膜出血
• [Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困难
• [Cough and expectoration (Sputumhlegm)] 咳嗽和咯痰
• [Hemoptysis] 咯血
• [Cyanosis] 紫绀
• [Palpitation] 心悸
• [Chest discomfort] 胸闷
• [Nausea (Retch;Dry Vomiting)and Vomiting] 恶心和呕吐
• [Hematemesis (Vomiting of blood)] 呕血
• [Hematochezia (Hemafecia)] 便血
• [Diarrhea] 腹泻
• [Constipation (Obstipation)] 便秘
• [Vertigo (Giddiness; Dizziness)] 眩晕
• [Jaundice (Icterus)] 黄疸
• [Convulsion] 惊厥
• [Disturbance of consciousness] 意识障碍
• [Hematuria] 血尿
• [Frequent micturition,urgent micturition and dysuria] 尿频，尿急和尿痛
• [Incontinence of urine] 尿失禁
• [Retention of urine] 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
• [Dehydration (Inanition)fever] 脱水热
• [Drug fever] 药物热
• [Functional hypothermia] 功能性低热
• [Absorption fever] 吸收热
• [Central fever] 中枢性发热
• [Fever type] 热型
• [Continuous fever] 稽留热
• [Remittent fever] 驰张热
• [Intermittent fever] 间歇热
• [Undulant fever] 波状热
• [Recurrent fever] 回归热
• [Periodic fever] 周期热
• [Irregular fever] 不规则热
• [Ephemeral fever] 短暂热
• [Double peaked fever] 双峰热
• [Fever of undetermined(unknown) origin, FUO] 不明原因发热
• [Rigor (shivering;chill;shaking chill;ague)] 寒战
• [Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒
• [Ultra-hyperpyrexia] 超高热
• [Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高热
• [Moderate fever] 中度发热
• [Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低热
• [Become feverish (Have a temperature)] 发热
• [Crisis] 骤降
• [Lysis] 渐降
• [Typhoid fever] 伤寒热
• [Rheumatic fever] 风湿热
• [Cancerous fever] 癌性发热
• [Fervescence period] 升热期
• [Defervescence period] 退热期
• [Persistent febrile period] 持续发热期
（2）疼痛的表示方法
• [Backache (Back pain)] 背痛
• [Lumbago] 腰痛
• [Headache] 头痛
• [Vasomotor headache] 血管舒缩性头痛
•[Post-traumatic headache] 创伤后头痛
•[Migraine headache] 偏头痛
• [Cluster headache] 丛集性头痛
• [Chest pain] 胸痛
• [Precardial pain] 心前区痛
• [Retrosternal pain] 胸骨后痛
• [Abdominal pain (Stomachache)] 腹痛
• [Acrodynia (pain in limbs)] 肢体痛
• [Arthrodynia (Arthralgia)] 关节痛
• [Dull pain] 钝痛
• [Sharp pain] 锐痛
• [Twinge pain] 刺痛
• [Knife-like pain (Piercing pain)] 刀割（刺）样痛
• [Aching pain] 酸痛
• [Burning pain] 烧灼痛
• [Colicky (Griping;cramp) pain] 绞痛
• [Colic] 绞痛
• [Bursting pain] 胀痛（撕裂痛）
• [Hunger pain] 饥饿痛
• [Tic pain] 抽搐痛
• [Bearing-down pain] 坠痛
• [Shock-like pain] 电击样痛
• [Jumping pain] 反跳痛
• [Tenderness pain] 触痛（压痛）
• [Girdle-like pain] 束带样痛
• [Wandering pain] 游走性痛
• [Throbbing pain] 搏动性痛
• [Radiating pain] 放射性痛
• [Cramping pain] 痉挛性痛
• [Boring pain] 钻痛
• [Intense pain] 剧痛
• [Writhing pain] 痛得打滚
• [Dragging pain] 牵引痛
• [Labor pain] 阵痛
• [Cancerous pain] 癌性疼痛
• [Referred pain] 牵涉痛
• [Persistent pain (Unremitting pain)] 持续性痛
• [Constant pain] 经常性痛
• [Intermittent pain] 间歇性痛
（3）水肿的表示方法
• [Mucous edema (Myxedema)] 粘液性水肿
• [Cardiac (Cardiogenic) edema] 心源性水肿
• [Nephrotic (renal) edema] 肾源性水肿
• [Hepatic edema] 肝源性水肿
• [Alimentary (Nutritional) edema] 营养不良性水肿
• [Angioneurotic edema] 血管神经性水肿
• [Pitting] 凹陷性
• [Nonpitting] 非凹陷性
• [Localized (Local) edema] 局限性水肿
• [Generalized edema (Anasarca)] 全身性水肿
• [Hydrops] 积水
• [Elephantiasic crus] 橡皮肿
• [Cerebral(Brain) edema] 脑水肿
• [Pulmonary edema (Hydropneumonia0] 肺水肿
• [Hydrocephalus] 脑积水
• [Edema of endoscrinopathy] 内分泌病性水肿
• [Invisible (Recessive) edema] 隐性水肿
• [Frank edema] 显性水肿
• [Inflammatory edema] 炎性水肿
• [Idiopathic edema] 特发性水肿
• [Cyclical edema] 周期性水肿
• [Ascites (Abdominal effusion;hydroperiotoneum)] 腹水
• [Pleural effusion (Hydrothorax)] 胸水
• [Pericardial effusion (Hydropericardium)] 心包积液
• [Bronchoedema] 支气管水肿
• [Slight (Mild)] 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
• [Cardiac dyspnea] 心原性呼吸困难
• [Inspiratory] 吸气性
• [Expiratory] 呼气性
• [Mixed] 混合性
• [Obstructive] 梗阻性
• [Dyspnea at rest] 静息时呼吸困难
• [Dyspnea on exertion] 活动时呼吸困难
• [Dyspnea on lying down] 躺下时呼吸困难
• [Paroxysmal nocturnal dyspnea,PND] 夜间阵发性呼吸困难
• [Orthopnea] 端坐呼吸
• [Asthma] 哮喘
• [Cardiac asthma] 心源性哮喘
• [Bronchial asthma] 支气管性哮喘
• [Hyperpnea] 呼吸深快
• [Periodic breathing] 周期性呼吸
• [Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)]气促
• [Bradypnea (Slow breathing)] 呼吸缓慢
• [Irregular breathing] 不规则呼吸
（5）皮肤粘膜出血的表示方法
• [Bleeding spots in the skin] 皮肤出血点
• [Petechia] 瘀点
• [Eccymosis] 瘀斑
• [Purpura] 紫癜
• [Splinter hemorrhage] 片状出血
• [Oozing of the blood (Errhysis)] 渗血
• [Blood blister (Hemophysallis)] 血疱
• [Hemorrhinia (Nasal bleeding)] 鼻衄
• [Ecchymoma] 皮下血肿
（6）咳嗽与咯痰的表示方法
• [Dry cough (Nonproductive cough;hacking cough)] 干咳
• [Sharp cough] 剧咳
• [Wet cough (Moist cough)] 湿咳
• [Productive cough (Loose cough)] 排痰性咳
• [Chronic cough] 慢性咳嗽
• [Irritable cough] 刺激性咳嗽
• [Paroxysmal cough] 发作性（阵发性）咳嗽
• [Cough continually] 持续性咳嗽
• [Spasmodic cough] 痉挛性咳嗽
• [Whooping cough] 百日咳
• [Winter cough] 冬季咳
• [Wheezing cough] 喘咳
• [Short cough] 短咳
• [Distressed cough] 难咳
• [Shallow cough] 浅咳
• [Droplet] 飞沫
• [Frothy sputum] 泡沫样痰
• [Bloody sputum] 血痰
• [Mucous (Mucoid) sputum] 粘液样痰
• [Purulent sputum] 脓痰
• [Mucopurulent sputum] 粘液脓性痰
• [White (Yellow,green) sputum] 白（黄,绿）痰
• [Fetid (Foul) sputum] 恶臭痰
• [Iron-rust (Rusty) sputum] 铁锈色痰
• [Chocolate coloured sputum] 巧克力色痰
• [Thick sputum] 浓痰
• [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）内脏出血的表示方法
• [Goldstein’s hemoptysis]戈耳斯坦氏咯血
• [Massive hematemesis]大量呕血
• [Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)]鼻衄
• [Hematuria] 血尿
• [Initial hematuria] 初血尿
• [Idiopathic hematuria] 特发性血尿
• [Painless hematuria] 无痛性血尿
• [Terminal hematuria] 终末性血尿
• [Gross (Macroscopic) hematuria] 肉眼血尿
• [Microscopic hematuria] 镜下血尿
• [Hematuria in the whole process of urination] 全程血尿
• [Gingival bleeding (Ulaemorrhagia;gum bleeding)] 牙龈出血
• [Hematochezia] 便血
• [Bloody stool] 血便
• [Black stool (Melena)] 黑便
• [Tarry stool] 柏油样便
• [Bleeding following trauma] 外伤后出血
• [Spontaneous bleeding] 自发性出血
• [Bleeding Continuously] 持续出血
• [Occult blood,OB] 隐血
• [Hematobilia] 胆道出血
• [Hemathorax] 血胸
• [Hemarthrosis] 关节积血
• [Hematocoelia] 腹腔积血
• [Hematoma] 血肿
• [Hemopericardium] 心包积血
• [Cerebral hemorrhage] 脑出血
• [Subarachnoid hemorrhage(SAH)] 蛛网膜下腔出血
• [Excessive (Heavy) menstrual flow with passage of clots] 月经量多伴血块
• [Mild (Moderate) menses] 月经量少（中等）
• [Painless Vaginal bleeding] 无痛性阴道出血
• [Postcoital bleeding] 性交后出血
• [Pulsating bleeding] 搏动性出血
• [Post-operation wound hemorrhage] 术后伤口出血
• [Excessive bleeding after denal extraction] 拔牙后出血过多
（8）紫绀的表示方法
• [Congenital cyanosis] 先天性紫绀
• [Enterogenous] 肠源性
• [Central] 中枢性
• [Peripheral] 周围性
• [Mixed] 混合性
• [Acrocyanosis] 指端紫绀
（9）恶心与呕吐的表示方法
• [Vomiturition (Retching)] 干呕
• [Feel nauseated] 恶心感
• [Postprandial nausea] 饭后恶心
• [Hiccup] 呃逆
• [Sour regurgitation] 返酸
• [Fecal (Stercoraceous) vomiting] 吐粪
• [undigested food Vomiting] 吐不消化食物
• [Bilious Vomiting] 吐胆汁
（10）腹泻与便秘的表示方法
• [Moning diarrhea] 晨泻
• [Watery (Liquid)diarrhea] 水泻
• [Mucous diarrhea] 粘液泻
• [Fatty diarrhea] 脂肪泻
• [Chronic (Acute)] 慢性（急性）
• [Mild diarrhea] 轻度腹泻
• [Intractable (Uncontrolled)diarrhea] 难治性腹泻
• [Protracted diarrhea] 迁延性腹泻
• [Bloody stool] 血梗
• [Frothy stool] 泡沫样便
• [Formless (Formed)stool] 不成形（成形）便
• [Loose (Hard) stool] 稀（硬）便
• [Rice-water stool] 米泔样便
• [Undigested stool] 不消化便
• [Dysenteric diarrhea] 痢疾样腹泻
• [Inflammatory diarrhea] 炎症性腹泻
• [Osmotic] 渗透性
• [Secretory] 分泌性
• [Malabsorption] 吸收不良性
• [Lienteric] 消化不良性
• [Pancreatic diarrhea] 胰性腹泻
• [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] 器质性便秘
• [Habitual constipation] 习惯性便秘
• [Have a tendency to be constipated] 便秘倾向
（11）黄疸的表示方法
• [Latent (occult) jaundice] 隐性黄疸
• [Clinical jaundice] 显性黄疸
• [Nuclear icterus] 核黄疸
• [Physiologic icterus] 生理性黄疸
• [Icterus simplex] 传染性黄疸
• [Toxemic icterus] 中毒性黄疸
• [Hemolytic] 溶血性
• [Hepatocellular] 肝细胞性
• [Obstructive] 阻塞性
• [Congenital] 先天性
• [Familial] 家族性
• [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] 谵妄
• [Syncope (swoon; faint)] 晕厥
• [Drowsiness] 倦睡
（13）排尿的表示方法
• [Enuresis (Bed-wetting)] 遗尿
• [Anuria] 无尿
• [Emiction interruption] 排尿中断
• [Interruption of urinary stream] 尿线中断
• [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)] 尿频
• [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)] 排尿困难
• [Small urinary stream] 尿线细小
• [Void with a good stream] 排尿通畅
• [Guttate emiction (Dribbling following urination;terminal dribbling)] 滴尿
• [Bifurcation of urination] 尿流分叉
• [Residual urine] 残余尿
• [Extravasation of urine] 尿外渗
• [Stress incontinence] 压力性尿失禁
• [Overflow incontinence] 溢出性尿失禁
• [Paradoxical in continence] 反常性尿失禁
3．少见症状
• [Weekness( Debility; asthenia; debilitating)] 虚弱（无力）
• [Fatigue (Tire; lassitude)] 疲乏
• [Discomfort (Indisposition; malaise)] 不适
• [Wasting (thin; underweight; emaciation; lean)] 消瘦
• [Night sweating] 盗汗
• [Sweat (Perspiration)] 出汗
• [Cold sweat] 冷汗
• [Pruritus (Iching)] 搔痒
• [Asthma] 气喘
• [Squeezing (Tightness; choking; pressing) sensation of the chest] 胸部紧缩
（压榨）感
• [Intermittent claudication] 间歇性跛行
• [Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis)] 吞咽困难
• [Epigastric (Upper abdominal) discomfort] 上腹部不适
• [Anorexia (Sitophobia)] 厌食
• [Poor appetite (Loss of appetite)] 纳差
• [Heart-burn( Pyrosis)] 胃灼热
• [Stomachache( Pain in stomach)] 胃部痛
• [Periumbilial pain] 脐周痛
• [Belching (Eructation)] 嗳气
• [Sour regurgitation] 返酸
• [Abdominal distention(bloating)] 腹胀
• [Pass gas( Break wink)] 肛门排气
• [Small(Large) stool] 大便少（多）
• [Expel(Pass) worms] 排虫
• [Pain over the liver] 肝区痛
• [Lumbago] 腰痛
• [Pica(Parorexia; allotriophagy)] 异食癖
• [Dysmenorrhea] 痛经
• [Menoxenia (Irregular menstruation)] 月经不调
• [Polymenorrhea (Epimenorrhea)] 月经过频
• [Oligomenorrhea] 月经过少
• [Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea)] 经量过多
• [Hypomenorrhea (Scantymenstruation)] 经量过少
• [Menopause (Menostasia; menostasis)] 绝经
• [Amenorrhea (Menoschesis)] 闭经
• [Leukorrhagia] 白带过多
• [Asexuality (lack of libido)] 无性欲
• [Hyposexuality] 性欲低下
• [Hypersexuality] 性欲亢进
• [Prospermia (Ejaculatio praecox)] 早泄
• [Impotency (impotence)] 阳萎
• [Nocturnal emission (Spermatorrhea)] 遗精
• [Lack of potency] 无性交能力
• [Hair loss] 脱发
• [Joint pain (Arthralgia; arthrodynia)] 关节痛
• [Polydipsia (Excessive thirst)] 多饮（烦渴）
• [Polyphagia (Excessive appetite; hyperorexia; bulimia)] 多食
• [Cold (Heat) intolerance] 怕冷（热）
• [Dwarfism (Excessive height)] 身材矮小（高大）
• [Excessive sweating] 多汗
• [Hands tremble] 手抖
• [Obesity (Fatty)] 肥胖
• [Agitation (Anxiety;nervous irritability)] 焦虑（忧虑）
• [Mania] 躁狂
• [Hallucination] 幻觉
• [Aphasia (Logopathy)] 失语
• [Amnesia (Poor memorization;memory deterioration)] 记忆力下降
• [Hemianesthesia] 偏身麻木
• [Formication] 蚁走感
• [Tingling] 麻刺感
• [Hyperpathia] 痛觉过敏
• [Hypalgesia] 痛觉减退
• [Illusion] 错觉
• [Hemiplegia] 半身不遂
• [Insomnia (Poor sleepness;sleeplessness)] 失眠
• [Nightmare] 多梦
• [Numbness] 麻木
• [Pain in limbs (Acrodynia)] 肢体痛
• [Limitation of motion] 活动受限
• [Tetany] 手足抽搐
• [Discharge of pus] 流脓
• [Blurred vision(Hazy vision;blurring of vision; dimness of vision)]视物模糊
• [Burning (Dry) sensation] 烧灼（干燥）感
• [Tearing (Dacryorrhea;Lacrimation)] 流泪
• [Double vision (Diplopia)] 复视
• [Strabismus] 斜视
• [Hemianopia] 偏盲
• [Tired eyes (Eyestrain)] 眼疲劳
• [Foreign body sensation] 异物感
• [Lose the sight (Lose of vision)] 失明
• [Diminution of vision] 视力减退
• [Nictition] 眨眼
• [Ophthalmodynia (Eye-ache;ocular pain)] 眼痛
• [Photophobia] 畏光
• [Spots before the eyes] 眼前黑点
• [Deafness(Anacusia)] 耳聋
• [Auditory dysesthesia] 听力减退
• [Otalgia (Otodynia;pain in the ear ;ear-ache)] 耳痛
• [Stuffy feeling in the ear] 耳闭气
• [Tinnitus] 耳鸣
• [Outophony] 自声过强
• [Nasal obstruction (blockage)] 鼻塞
• [Dryness of the nose] 鼻干燥
• [Rhinorrhea (Snivel;Nasal discharge)] 流鼻涕
• [Sneezing] 打喷嚏
• [Snoring] 打鼾
• [Hyposmia (Reduction of the sense of smell)] 嗅觉减退
• [Anosmia (Complete loss of sense of smell)] 嗅觉丧失
• [Dysphonia] 发音困难
• [Hoarseness] 声嘶
• [Pain on swallowing] 吞咽痛
• [Saliva dribblies from the mouth] 流涎
• [Troaty voice] 声音沙哑
• [Stridor] 喘鸣
• [Red and swollen] 红肿
• [Scurf] 头皮屑
• [Show] 见红
• [Amniotic fluid escaped] 破水
• [Uterine contraction] 宫缩
• [Acalculia] 计算不能
• [Apathy] 情感淡漠
• [Delusion] 妄想
第三部分 现病史[History of present illness (HPI/PI)]
现病史书写的重点包括：
一、主诉中症状的详细描述；
二、疾病的发展过程；
三、诊疗经过；
四、目前的一般情况。
1、诱因
•无诱因下[With no inducing factors]
•无明显诱因下[Under no obvious predisposing causes]
•感冒一周后[After getting (catching) common cold for 1 week]
2、症状出现的叙述
•有……症状
•suffer from
• have an attack of
• have(fell)
• begin to fell
• a feeling (sensation) of……
• complain (of)
• ……sensation (feeling) in (of) ……
• [发热]have a temperature (become feverish)
•在……情况下发生
• 活动时呼吸困难[dyspnea on exertion]
• 躺下后即出现咳嗽[Cough occurs soon after lying]
•与……有（无）关
• 与……有关[be associated with]
• 与……有关[have (make) relation to]
• 与……无关[have (make)no relation to]
•在……情况下加重（减轻）
• 餐后加重[become worse after taking meals]
• 站立后缓解[be relieved by standing up]
• 随呼吸和咳嗽而加重[become more severe with breathing and cough]
•伴有……
• be accompanied by
3、起病方式
•急性腹痛[acute abdominal pain]
•慢性低热[chronic lower fever]
•暴发性发病[the onset was fulminating]
•骤起胸痛[an explosive onset of chest pain]
•突然起病伴高热[the onset was sudden with high fever]
•突发突止[attacks began and ended abruptly]
•因……而突然起病[the attack is precipitated by……]
•很快发生晕厥[syncope occured rapidly]
•逐渐出现咳嗽咳痰[gradual onset of cough and sputum]
•偶而[occasionally (sporadically, accidentally)]
•反复胸闷心悸[recurrent (bouts of) chest discomfort and palpitation]
•一过性发作[transitory attack]
•连续胸痛[chest pain continually]
•时重时轻[waned and waxed]
•时好时坏[hang in the balance]
•不停地咳嗽[have a fit of cough]
•发作性呼吸困难[paroxysmal short of breath]
•频繁咳嗽[cough frequently (very often)]
•持续性（间歇性）[persistent (intermittent)]
•频发胸痛[frequent episodes of chest pain]
•持续不变[be steady]
4、病情变化描述
•[症状好转] •fell better than before
•take a favorable turn
•take a turn for the better
•improve
•make favorable progress
•turn for the better
•change for the better
•be better
•[症状减轻] •alleviate
•reduce
•palliate
•diminish
•ease(lighten)
•mitigate
•[症状消失] •disappear
•subside
•regress
•clear up
•vanish
•dissolve
•die (fade) away
•relieve
•[症状加重] •be (make,become,get) worse
•worsen
•become more severe
•take a turn for the worse
•be aggravated
•increase in severity
•take a bad turn
•make (become) more serious
•make (become) heavier
•[无变化] •remain the same as……
•continue without change
•be identical
•be alike
•be similar
•resemble
•[时好时坏] •wane and wax
•hang in the balance
•[体温/血压升降]
• 升至[rise (go up) to ]
• 已升至[have risen (gone up) to ]
• 从……升至……[go up from …… to……]
• 升至[be elevated to]
• 迅速下降[fall (decline, abate) abruptly]
• 骤降（升）[sudden drop (elevation)]
• 渐降（升）[fall (elevate) gradually]
• 缓慢下降[slow crisis (lysis) of ]
• 一天天下降[be (become) lower day by day]
• 开始降低[begin to remit]
• 降至正常[drop (was reduced) to normal]
• 已降至[have gone down (dropped) to]
• 回复到正常[return (revert) to normal]
• 由……降（升）至……[fall (elevate) from……to……]
• 维持在……水平[maintain at a level of……]
• 稳定在……[stabilize at……]
• 热退了[fever disappeared]
• 不超过[do not go up over (exceed)……]
• 在……和……之间波动[fluctuate (vary) between……
and……]
• 在……至……范围内[range from……to……]
• 平均38.5℃[an average temperature of 38.5℃]
• 有39.2℃的体温[have fever (a temperature) of 39.2℃]
5、症状的时间表示
•持续 •lasted for 2 days
•have gone on for 1 month
•have continued for 10 hours
•lasted on the average 3-5 hours
•lasted a variable time from 5 minutes to several hours
•lasted about half an hour
•超过（不到）[move than (less than)]
•……以前[two years ago]
•多在……时发生[usually between 3 and 5 PM]
•未发作过[be free of onsets (attacks) for 2 weeks]
6、症状的严重程度
•轻度[mild (slight)]
•中度[moderate]
•重度[severe (serious)]
7、症状的其他描述方法
•[部位] •be located (situated) in (over)[位于]
•There is localized pain in……[疼痛位于]
•near……[在……附近]
•be localized to (in, over)[局限于]
•be limited (confined) to[局限于]
•[表示部位的介词]
•心尖部，表示小的部位或点[at the apex]
•上腹部，表示大的部位[in the upper abdomen]
•在左下肢，表示皮肤表面上（下）的病变[on (beneath) the
left lower limb]
•在右肺，表示正上方的相应体表部位[over the right lung]
•嘴上（下）方，表示高低或上下的位置关系[above (below)
the mouth]
•左乳皮下[under the skin of the left breast]
•[转移/放射]
•转移到……[shift (migrate) to……]
•放射到……[radiate (travel,go,refer)to……]
•从……放射到……[radiate from……to……]
•[耳鼻咽喉及口腔症状]
•耳痛[otalgia (pain of ears)]
•耳鸣[tinnitus (ears ring)]
•耳鸣[a buzzing (ringing,singing) in the ears]
•左耳有耳鸣感[a buzzing sensation in the left ear]
•耳聋[deafness (loss in hearing)]
•左耳聋[be deaf of the left ear]
•耳流脓[otorrhea (otopyorrhea)]
•耳出血[otorrhagia]
•耳垢[cerumen (earwax)]
•耳血肿[othematoma]
•鼻塞[nasal obstruction]
•不能用鼻呼吸[be unable to breathe through (by) the nose
(nasal dyspnea)]
•打喷涕和流涕[sneezing and nasal discharge]
•水样鼻涕[watery rhinorrhea]
•鼻出血[nosebleed]
•咽喉痛[sore throat]
•口吃[stuttering]
•口臭[ozostomia (saburra,halitosis)]
•张口困难[difficult (inability) to open the mouth]
•张口（吞咽、嚼）困难[difficult in opening the mouth
(swallowing，masticating)]
•咽下困难[dysphagia]
•流涎多[have excessive salvation]
•[眼科及牙科症状]
•眼睑浮肿[eyelid edema]
•眼痛[pain in the eyes]
•视边模糊[blurring of vision (blurred vision)]
•过度流泪[excessive tearing (watering)]
•视疲劳[asthenopia (visional tired)]
•视力减退[hypopsia (diminution of vision)]
•视力衰弱[ophthalmocopia]
•远（近）视力模糊[indistinct distant (near) vision]
•失明[loss of vision]
•搏动性牙痛[throbbing pain of tooth (odontalgia)]
•牙龈出血[gingival bleeding]
•牙龈萎缩（增生）[gingival atrophy(hypertrophy)]
•牙周溢脓[peripyema]
•[妇产科症状]
•月经过多[excessive menstrual flow (menorrhagia)]
•月经多并伴血块[experience menorrhagia with passage of
clots]
•经量少（中等、多）[mild (moderate,heavy) menses]
•月经过少[hypomenorrhea]
•阴道出血[vaginal bleeding(colporrhagia)]
•阴道大出血[massive (profuse) vaginal bleeding]
•无痛性（性交后）阴道出血[painless(postcoital) vaginal
bleeding]
•阴道干燥[colpoxerosis]
•月经规则（不规则）[rugular (irregular) menstrual cycle]
•月经周期26天，持续4天[menstrual periods of 26 days and
lasted 4 days]
•白带增多[leukorrhagia (profuse leukorrhea or whites)]
•外阴搔痒[pruritus of vulva]
•外阴湿疹（白斑）[eczema (leukoplakia) of vulva]
•绝经[amenorrhea]
•停经[menopause]
•停经3年[3 years post menopausal]
•50岁停经[Passed menopause at age 50]
•经前（期）痛[pain before (during) the flow]
•预产期[expected date of confinement]
•见红和破水[show and amniotic fluid escaped (rupture of
membranes)]
•羊水过多（少）[polyhydramnios (oligohydramnios)]
•月经期水肿[menstrual edema]
•月经失调[menstrual disorder]
•性欲正常（减退）[normal(decreased) libido]
•无性欲[loss of libido]
•性功能障碍[sexual disorder]
•性变态[paraphilia]
•性要求高（低）[be oversexed(undersexed)]
•性感不快[dypareunia]
•性欲亢进（减退）[hypersexuality (hyposexuality)]
•产程[stage of labor]
•产程延长[prolonged labor]
•产道裂伤（损伤）[laceration (injury) of birth canal]
•产后腹痛（出血，尿潴留，子痫）[postpartum tormina
(hemorrhage,retention of urine, eclampsia)]
•产前出血[antepartum hemorrhage]
•产前子痫[prenatal eclampsia]
•产前检查[prenatal examination]
•产褥热[puerperal fever]
•产褥期护理[pureperal care]
•妊娠呕吐[vomiting of pregnancy (hyperemesis gravidarum)]
•妊娠反应[pregnancy reaction]
•妊娠高血压（水肿）[gestation hypertension (edema)]
•[病程中的一般情况]
•一般情况尚可（一般、差）[general condition is fair (ordinary, bad)]
•胃纳佳（差）[have a good (poor) appetite]
•过度进食[eat too much (overeat, eat heavily)]
•过少进食[eat poorly (take little food)]
•无食欲[have no appetite]
•食欲减退[appetite decreases]
•口渴[feel thirsty]
•大量饮水[drink water generously]
•体重增加[gain in weight]
•体重增加8公斤[a 8 kilograms weight gain (gain 8 kilograms)]
•体重减轻[loss of weight (weight loss)]
•体重稳定不变[body weight is stable (unchanged, maintained)]
•睡眠障碍[somnipathy]
•睡眠不足[lack (want) of sleep]
•不易入睡[have trouble getting to sleep]
•容易入睡[fall into a sleep very easily]
•睡眠过度[hypersomnia]
•睡行症[sleep walking]
•嗜（贪）睡[somnolence (be fond of sleep)]
•夜晚因……而易醒[easily wakened at night because of……]
•失眠[have insomnia]
•睡眠差（好）[sleep is poor (good)]
•消化不良[dyspepsia (have bad digestion)]
•大（小）便通畅[stool (urination) is easy and smooth(unobstructed, clear)]
•每日2次大便[have two stools daily]
•含粘液的水样便[watery stools coutaining mucus]
•便秘（腹泻）[constipation (diarrhea)]
•排尿困难[difficulty in micturition]
•尿频（急）[frequency(urgency) of micturition]
•尿痛[micturition pain]
•少尿（无尿、多尿）[oliguria (anuria, polyuria)]
•大便失禁[fecal incontinence]
•小便失禁[incontinence of urine]
•精神不振[lassitude]
•精神紧张（抑郁）[mental stress (depression)]
•精神混乱[confusion]
•精神失常[amentia (mental state is bad)]
•精神状态正常[orthophrenia (mental state is good)]
•体力旺盛（不足，正常）[hypersthenia (hyposthenia, euthesia)]
第四部分 过去史、系统回顾和个人史
（Past history, systems review and personal history）
1、过去史[past history]
•无药物（食物）过敏史[no past history of allergy to drugs (food )]
•有青霉素过敏史[have allergic history of pencillin]
•有肺结核接触史[there was contact histoy of lung tuberculosis]
•2000年6月因急性阑尾切除术[Appendectomy was done in June, 2000 due to acute appendicitis]
•健康状况佳（差）[health state was good (bad)]
•既往体健[be well (healthy) before]
•否认既往心、肺疾病史[deny any history of prior heart and lung disease]
•10岁时（20年前）曾患过……[suffered from…… at age 10(20 years ago)]
•易患……[be liable (subjuct, apt) to……]
•不详[not in detail (not quite clear)]
•外伤史[rtauma history]
•预防接种史[history of preventive inoculation]
2、系统回顾[system review]
•呼吸系统：咳嗽、咳痰、呼吸困难、胸痛、盗汗、发热[respiratory system: cough, sputum, short of breath, chest pain, night sweeting, fever.]
•循环系统：心悸、胸痛、气促、咳嗽和咯血、水肿、晕厥、头晕[Circulatory system: palpitation, chest pain, short of breath, cough and hemoptysis, edema, syncope, dizziness.]
•消化系统：嗳气、返酸、腹胀、腹痛、腹泻、恶心和呕吐[alimentary system: belching, sour regurgitation, abdominal distension, abd. pain, diarrhea, nausea and vomiting.]
•泌尿系统：排尿困难、尿频和尿急、尿痛、腹痛、水肿[urinary system: difficulty in micturition, frequency and rugency of micturition, painful micturition, abdominal pain, edema.]
•造血系统：乏力、头晕、心悸、出血[hematopoietic system:fatigue, dizziness, palpitation, bleeding.]
•内分泌系统：心悸、怕热、多汗、烦渴、水肿、手抖、消瘦和肥胖[endocrine system: palpitation, heat intolerance, excessive sweeting, polydipsia, edema, hand tremble, wasting and obesity.]
•神经系统：头痛、晕厥、头晕和眩晕、失眠、偏瘫、失语[nervous system: headache, coma, dizziness and vertigo, insomnia, hemiplegia, aphasia.]
•运动系统：关节痛、麻木、跛行、瘫痪[motor system: joint pain, numbness, claudication, paralysis.]
3、个人史[personal history]
•出生于（出生地）[was born in (birthplace)]
•出生后一直生活[have lived in……(there) since birth]
•曾（未曾）去过北方[have (deny having) been to the north]
•受教育程度（文盲、小学、中学、大学）[educational level (illiterate, primary, middle, high grade)]
•业余爱好[hobby (be fond of, be keen of, interest)]
•从事……职业[be engaged in]
•卫生习惯和嗜好[health habit and special addiction]
•不洁性交（性行为）史[history of unclean coitus (sexual behavior)]
•不吸烟[ no smoking(not a smoker)]
•吸烟20年，每天2包[have smoked two packages of cigarette a day for 20 years]
•戒烟[give up (stop) smoking]
•戒烟[smoking abstinence (withdrawal)]
•不饮酒[no alcohol use]
•偶而少量饮酒[drink little liquor occasionally]
•过度饮酒[drink heavily (too much)]
•每天饮酒0.5公斤[drink (imbibe) about 0.5 kilogram a day]
•酒精性饮料[alcoholic beverage]
•偏食[food preference (particular with food)]
•无偏食[no likes or dislikes in food]
•偏爱……[have partiality for (showe favoritism to, be partial to, like)]
第五部分 月经、婚姻、生育史和家族史
Menstrual, marrital and childbearing history and family history]
1、月经史[menstrual history]
•初潮年龄[age of menarche]
•月经周期[menstrual cycle]
•行经期[menstrual period]
•未次月经时间[last menstrual period (LMP)]
•闭经年龄[age of menostasis]
•白带过多[profuse leukorrhea (whites)]
•月经过多[menorrhagia (hypermenorrhea, menometrorrhagia)]
•月经过少[hypomenorrhea (scantymenstruation)]
•月经过频[polymenorrhea]
•月经稀发[oligomenorrhea]
•月经不调[menoxenia (irregular menses, menstrual disorder)]
•月经正常[eumenorrhea (regular menses)]
•经前水肿（疼痛）[premenstrual edema (pain)]
•经量少（中、大）量[mild (moderate, heavy) meustrual blood]
•痛经[dysmenorrhea (pain during the flow)]
•36岁就停经了[pass the menopause at age 36]
2、婚姻史[marrital history]
•未婚（已婚）[single (married)]
•结婚年龄[age of wedding]
•配偶的健康状况[health status of partner (spouse)]
•性生活和谐（不和谐）[sexual life is harmonious (disorder)]
•夫妻关系和睦（不和睦）[relation of husband and wife is amicable (hostile)]
•近亲（非近亲）结婚[consanguineous (nonconsanguineous) marriage]
3、生育史[childbearing history]
•妊娠（生育）次数和年龄[times and age of pregnancy (childbearing)]
•怀孕和生产次数[pregnancies and labors]
•人工（自然）流产次数[times of induced (spontaneous) abortion (miscarriage)]
•流产 [miscarriage(abortion)]
•死胎（产）[dead fetus (birth)]
•割腹产[caesarean birth (be born by caesarean section)]
•子女数[number of children]
•早产（儿）[premature birth (bady)]
•足月产[term labor]
•产褥热（感染）[puerperal fever (infection)]
•计划生育[family planning (birth control)]
•用避孕环（药、油膏、套、栓）避孕[contraception by intrauterine ring (contraceptives, ointment, condom, supposity)]
•节育手术[contraceptive operation]
•自然分娩[be delivered normally and spontaneously(spontaneous labor)]
•产钳分免[forceps delivery(be delivered by forceps)
•产前（后）子痫[antepartum(postpartum) eclampsia]
•出生时3.5公斤重，48厘米高[3.5 kilograms and 48cm in height at birth]
•母乳喂养[breast feeding (be fed at breast)]
•人工喂养[artificial feeding]
•发育正常[normal development]
•发育异常(停顿、缺陷、畸形)[developmental anomaly(arrest,defect,deformity)]
•发育迟缓（过渡）[hypoevolutism(hypergenesis)]
4、家庭史[family history]
•父母（兄弟，姐妹和儿女）的健康状况和疾病情况[health status and illness
of parents (brothers,sisters and children)]
•同样疾病[the same sickness]
•遗传疾病[heredopathia (genetic disease)]
•遗传特征[hereditary feature]
•死因[cause of death]
•健康[be healthy (be in good healthy)]
•健在[be living and well]
•无……家族史[no family history of ……]
•死于……[die of……]
3万+
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