英文病历常用表述方式
Terminologies in Medical Records
症状发作Complain of/have a feeling (sensation) of/suffer from/have an attack of/have (fell)/begin to fell
2. 疾病诱因
无诱因with no inducing factors无明显诱因 under no obvious predisposing causes/without apparent inducement活动时呼吸困难 dyspnea on exertion与……有关 be associated with/have(make) relation to与……无关 have (make) no relation to伴发 be accompanied by感冒一周后 after getting (catching) common cold for one week3. 起病方式
突发胸痛 an explosive onset of chest pain急性腹痛 acute abdominal pain持续性胸痛 chest pain continually反复胸闷心悸 recurrent (bouts of) chest discomfort and palpitation频发胸痛 frequent episodes of chest pain发作性呼吸困难 paroxysmal short of breath慢性低热 chronic lower fever突然起病伴高热 the onset was sudden with high fever因……而突然发作 the attack is precipitated by很快发生 occur rapidly偶尔 occasionally, sporadically, accidentally逐渐出现咳嗽咳痰 gradual onset of cough and sputum一过性发作 transitory attack频繁 frequently持续性（间歇性） persistent (intermittent) 4. 病情变化描述
好转 fell better than before; be better; take a favorable turn; improve; turn for the better症状减轻 alleviate; reduce; palliate; diminish症状消失 relieve; disappear; regress; clear up; vanish; dissolve症状加重 be (become, get) worse; worsen; take a turn for the worse; be aggravated; increase in severity; take a bad turn无变化 be alike; be similar; continue without change; be identical; resemble体温/血压升降法升至 rise (go up) to/ be elevated to已升至 have risen (gone up) to已降至 have gone down (dropped) to骤降/升 sudden drop/elevation渐降/升 fall/elevate gradually降至正常 drop/was reduced to normal回复到正常 return/revert to normal维持在……水平 maintain at a level of稳定在……stabilize at不超过 do not exceed/go up over在…..之间波动 fluctuate/vary between…and…
5. 时间
持续 last for/have continued for超过/不到 more than/less than多在……时发生 usually in the morning2周未发作过 be free of onsets/attacks for 2 weeks
6. 严重程度
轻度/中度/重度 mild (slight)/moderate/severe (serious)
7. 其他
部位Be located/situated in/over 位于…
There is localized pain in…疼痛位于…
Near…在…附件
Be localized to/in/over…局限于
Be limited/confined to 局限于
At the apex心尖部（表示小的部位/点可用 at）
In the upper abdomen 上腹部（表示大的部位可用in）
On/beneath the left lower limb 在左下肢（表示皮肤表面上/下的病变可用on）
Over the right lung 在右肺（表示正上方的可用over）
Above/below the mouth 嘴上/下方（表示高低/上下的位置关系）
Under the skin of the left breast 左乳皮下
转移到 shift (migrate) to…（疼痛）放射到 radiate/travel/go/refer to从…放射到…radiate from…to…耳鼻咽喉及口腔耳痛 otalgia /pain of ears
耳鸣 tinnitus/ ears ring/a buzzing in the ears
耳聋 deafness/loss in hearing
鼻塞 nasal obstruction
打喷嚏和流鼻涕 sneezing and nasal discharge
水样鼻涕 watery rhinorrhea
鼻出血 nosebleed
咽喉痛 sore throat
吞咽困难 difficult in swallowing
流涎多 have excessive salvation
眼科及牙科眼睑水肿 eyelid edema
眼痛 pain in the eyes
视疲劳 asthenopia (visional tired)
视力减退 hypopsia (diminution of vision)
视力模糊 indistinct vision
失明 loss of vision
牙痛 pain of tooth/odontalgia
牙龈出血 gingival bleeding
牙龈增生/萎缩 gingival hypertrophy/atrophy
妇产科经量少 mild menses
月经过少 hypomenorrhea
阴道出血 vaginal bleeding
月经不规则 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
绝经 amenorrhea
停经 menopause
经期痛 pain during the flow
预产期 expected date of confinement
羊水过多（少） polyhydramnios/oligohydramnios
月经失调 menstrual disorder
经期水肿 menstrual edema
性欲减退 decreased libido
产程 stage of labor
产程延长 prolonged labor
产前出血 antepartum hemorrhage
产前子痫 prenatal eclampsia
产前检查 prenatal examination
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
一般情况一般情况尚可/差 general condition is fair/bad
纳差 have a poor appetite
多食eat too much/overeat/eat heavily
少食 eat poorly/take little food
食欲减退 appetite decreases
口渴 feel thirsty
多饮 drink water generously
体重增加 gain in weight
体重增加…公斤 a…kilograms weight gain/gain…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
睡眠过度 hypersomnia
嗜睡somnolence/be fond of sleep
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
每日大便2次 have two stools daily
便秘/腹泻 constipation/diarrhea
排尿困难 difficulty in micturition
尿频/尿急 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
精神状态正常 orthophrenia/mental state is good
精神不振 lassitude
精神紧张/抑郁 mental stress/depression
病历内容 Contents of Medical Records
既往史、系统回顾和个人史
Past history, system review and personal history
既往史 past history无药物（食物）过敏史No past history of allergy to drugs(food)有过敏史have allergic history of有肺结核接触史 there was contact history of lung tuberculosis健康状况佳（差）health state was good (bad)既往体健 be well (healthy) before不详 not in detail (not quite clear)否认既往心、肺疾病史 deny any history of prior heart and lung disease10年前曾患过…suffer from…10 years ago外伤史 trauma history预防接种史 history of preventive inoculation2. 系统回顾 system review
循环系统：气短、心悸、胸痛、咳嗽、咯血、水肿、晕厥Circulatory system: short of breath, palpitation, chest pain, cough, hemoptysis, edema, syncope
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 sweating, fever
消化系统：嗳气、发酸、腹胀、腹痛、腹泻、恶心和呕吐Alimentary system: belching, sour regurgitation, abdominal distension, abdominal 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 urgency of micturition, painful micturition, abdominal pain, edema
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 sweating, polydipsia, edema, hand tremble, wasting and obesity
造血系统：乏力、头晕、心悸、出血Hematopoietic system: fatigue, dizziness, palpitation, bleeding
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, and 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……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)从事…职业be engaged in卫生习惯和嗜好health habit and special addiction不洁性行为史history of unclean coitus不吸烟 no smoking(not a smoker)吸烟10年，每天1包have smoked one packages of cigarette a day for 10 years戒烟give up (stop) smoking不饮酒 no alcohol use偶尔饮酒 drink little liquor occasionally大量饮酒 drink heavily (too much)偏食 food preference无偏食 no likes or dislikes in food4. 月经史menstrual history
初潮年龄age of menarche月经周期menstrual cycle经期menstrual period末次月经时间last menstrual period(LMP)月经正常eumenorrhea (regular menses)闭经年龄 age of amenorrhea月经过多 menorrhagia(hypermenorrhea,meno-metrorrhagia)月经过少hypomenorrhea月经过频 polymenorrhea痛经 dysmenorrhea(pain during the flow)月经不调 menoxenia(irregular menses, menstrualdisorder)白带过多 profuse leukorrhea经前疼痛（水肿）premenstrual pain (edema)经量少/中/大mild/moderate/heavymenstrual blood停经年龄pass the menopause at age…
5. 婚姻史marital history
未婚/已婚single/married结婚年龄age of wedding配偶健康状况health status of partner(spouse) 近亲/非近亲结婚 consanguineous/nonconsanguineous marriage
6. 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
· 流产 abortion/miscarriage
· 人工/自然流产次数 times of induced/spontaneous abortion/miscarriage
· 死胎dead fetus
· 早产premature birth
· 足月产 term labor
· 自然分娩 be delivered normally and spontaneously(spontaneous labor)
· 子女数number of children
· 产前/后子痫antepartum/postpartum eclampsia
· 母乳/人工喂养breast/artificial feeding
· 发育正常 normal development
· 发育异常/畸形/缺陷 developmental anomaly/deformity /defect
· 发育迟缓hypoevolutism
7. 家族史 family history
· 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