大病例中英文对照

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大病历模板(英文)

Union Hospital affiliated to Huazhong University of Science and TechnologyAdmission Record 0000337023 Department: Respiratory Medicine Area: J17 Respiratory Medicine Bed No. 109031 Case No. 1565825Name: Hou Deguang Gender: Male Date of Birth: 15/9/ 1936 Age: 78 Nationality: ChinaID No. Ethnicity: Han Occupation: other Marital status: MarriedAddress: Nanchong，Sichuan Tel No.Source of History: Patient herself Reliability: ReliableAdmission Date & Time: 4/11/2014 14:36Chief Complaint: Found pleural effusion for about 2 months.Present Illness: The patient received the chest CT scan in the Wuhan Traditional Medicine Hospital two months ago and found right-side pleural effusion, right-side pulmonary atelectasis. After that,he was hospitalized in the Endocrinology Dept of our hospital for poor management of bloodglucose level. On this admission, He received the thoracocentesis, and the laboratoryexamination results indicated the large possibility of tuberculous pleural effusion. No specialtreatment was given at that time. The patient was aware of a sense of polypnea after long walk,without cough, expectoration, night sweats, chest distress, thoracalgia, wheeze, dyspnea andcan lie down to sleep at night. The return-visit in the clinic at October 13th showed that therewere a few pleural effusion on the right side and is hard to be localized. Now the patient cameto our hospital for further treatment and was admitted as “Pleural effusion origin unknown”.Since the onset of the disease, the patient’s spirit, appetite and sleep are normal. Nocturia for 1time per night. Stool are as usual. No obvious weight and physical strength change.Past History: General Health Status: Relatively bad; Respiratory Syste m: Chronic bronchitis for about 10 years; Circulatory System: Hypertension for about 20 years, highest reached 180/95mmHg, tookAmlodipine orally 5mg qd, BP management is good. Diagnosed of coronary heart disease in2007, underwent intracoronary stent implantation in 2008, 3 stents were implanted; DigestiveSystems: None; Urinary System: Benign prostatic hyperplasia for about 5 years, Diabeticnephropathy for 3 years; Hematologic System: Thrombocytopenia for 2 years; EndocrineSystem: None. Nervous System: Lacunar infarction in 2011; Motor System: None; InfectionHistory: No infection of hepatitis and TB. Others: None special; Preventive Inoculation: Inaccordance with the stateplan; Operation History: underwent intracoronary stent implantationin 2008, 3 stents was implantated; Blood Transfusion History: None; Traumatic History: None;Allergic History: None;Personal History: Habitual Residence: Hubei; Residential Environment: No exposure history to toxic substances and infected water; Travelling History: None; Smoking History: Smoking forabout 40 years, 3 cigarettes per day. Quit smoking in 2008; Drinking History: Drinking for 40years, 150g-350g per day, Quit drinking in 2008;Marital History: Married,Menstrual History: MaleFamily History: Father is deceased, mother is deceased. No other infective and hereditary diseases.Physical ExaminationVital Signs: T:36.5℃. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Height: 164cm. Weight: 64kg.Expression: Normal. Development: Well. Nutritional status: Fairly. Consciousness: Conscious. Spirit: Well. Gait: Normal. Position: Active. Coordination with Examination: Cooperative.Skin and Lymph Nodes: No jaundice. Some scattered scratch in hands and abdomen, No subcutaneousbleeding, edema, nodules or unusual pigmentation. Liver palm(-). Spider angioma(-). Noswelling of general superficial lymph nodes.HEENT(Head, Eye, Ear, Nose, Throat): Normal skull. No baldness, no scars. Eyes: No ptosis. Conjuctiva normal.The pupils are round, symmetric and responsive to light and accommodation is normal. Ears:Externally normal. Canals clear. Drums normal. Noses: No abnormalities noted. Month andThroat: lips red, tongue red, no swelling of tonsils.Neck: Motion free. Thyroid is not enlarged. No abnormal pulsations. Trachea in middle. Carotid: Pulse is normal.Hepatojugular reflux sign(-). Vascular bruit: None.Chest and Lung: Normal contour. Breast normal. Inspection: respiratory movement symmetric and regular.Palpation: Normal and symmetric. No pleural friction fremitus. Percussion: both sides resonance.Auscultation: right-side breath sounds weaken, left-side is normal. No moist or dry rales. No pleural friction rubs.Heart: No protrusion of precordium. Normal apical impulse. No thrill. No enlarged cardiac dullness border. Heart rate: 88bpm, rhythm normal. No abnormal and extra cardiac sounds or cardiac murmurs. No peripheralvascular signs.Abdomen: Flat abdomen. No gastric or intestinal pattern. No visible peristalsis. Normal bowel sound. No rigidity.No mass palpable. No tenderness and rebound tenderness. Liver and spleen are not palpable. Kidneysare not palpable. No percussion tenderness over kidney regions. No shifting dullness.Rectum: Normal anus and perineum.Genitourinary System: Normal.Neural System: Normal.Extremities: No joint disease. Muscle strength normal. Pathological reflex (-).Specialty Examination: Right-side breath sounds weaken, left side normal. No moist or dry rales, No swelling of general superficial lymph nodes. No edema in neither lower extremities.Accessory Examination: Discharge record of Endocrinology Dept. of our hospital at September 2014; Clinic examination at October 13th: a few pleural effusion on the right side and is hard to belocalized.History summary: 1. Hou Deguang, male, 78 yr.2. Admitted for ”Found plaural effusion for about 2 months”.3. T:36.5℃. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Expression: Normal.Spirit clear. Cardiac sounds normal, HR: 72 bpm, rhythm normal, No abnormal and extra cardiacsounds or cardiac murmurs. Right-side breath sounds weaken, left side normal. No moist or dry rales,no pleural friction rubs. Flat abdomen. No rigidity.4. Special examination: Trachea in middle. Contour symmetric. Respiratory movement regular.Right-side breath sounds weaken, left side normal. No moist or dry rales, no pleural friction rubs.5. Accessory Examination: Discharge record of Endocrinology Dept of our hospital atSeptember 2014; Clinic examination at October 13th: a few pleural effusion on the right side andis hard to be localized.6. Past history: Respiratory Syste m: Chronic bronchitis for about 10 years; CirculatorySystem: Hypertension for about 20 years, highest reached 180/95mmHg, took Amlodipine orally5mg qd, BP management is good. Diagnosed of coronary heart disease in 2007, underwentintracoronary stent implantation in 2008, 3 stents was implantated; Digestive Systems: None;Urinary System: Benign prostatic hyperplasia for about 5 years, Diabetic nephropathy for 3years; Hematologic System: Thrombocytopenia for 2 years; Endocrine System: None. NervousSystem: Lacunar infarction in 2011; Motor System: None; Infection History: No infection ofhepatitis and TB. Others: None special; Preventive Inoculation: In accordance with the stateplan;Operation History: underwent intracoronary stent implantation in 2008, 3 stents wasimplantated; Blood Transfusion History: None; Traumatic History: None; Allergic History:None;Impression: 1. Right-side pleural effusion origin unknown: TB? Tumor?2. II diabetes mellitus, Diabetic nephropathy3. Hypertension III, high risk4. Coronary heart disease, post-intracoronary stent implantation5. Lacunar infarction6. Thrombocytopenia7. Benign prostatic hyperplasiaRecorder: Cheng LongDate & Time: 4/11/2014 16:14Checker: Xu JuanjuanDate & Time: 5/11/2014 10:22。

【精品】英文大病历

【关键字】精品Complete Medical HistoryName: Zhanghou Sex: maleProfession :peasant Age:31 yearsNative place: Tian Jin Address:chitu village chitu town dongli district tianjinMarital state: married Nationality: HanDate of admission: February 28 2003 Date of history taking :February 28 2003 Narrator: the patient Reliability of the history: reliableThe HistoryChief Complaint: lumbago for 2 years with weakness ,numbness in lower limbs, more severe 2 months.Present Illness:2 years ago ,after working ,the patient always felt lumbago, sometimes referred pain at the hip and lower extremities,mainly at the dorsal side.and the left lower limb was more severe. At the same time he felt weak and numb at lower limbs, also more severe in the left side. No muscle atrophy, no abnormal of stool and urine. No temperature abnormal or color changes in the local skin. No nails damaged. Then the patient went to the hospital in his town, and had a X-ray examination, shown hypertrophy in the lumbar vertebrae., given some drugs for pain-control. After having some drugs and more rest, the symptoms lightened. But 2 months ago ,without significant causes,the symptoms became more severe. The lumbago often made him sleepless at nights. And he can only walk 500 meters without a break. his left lower limb felt numb and weak.Having the drugs and rest both can not ease the symptoms. So he came to our hospital for advanced diagnosis and treatment. Since the disease, no changes in consciousness,body temperature, appetite, body weight .and normal of stool and urine.Past history: the patient had a history of high intensive working for about 10 years. No history of chronic diseases like hypertension, CAD and mellitus diabetics. No history of hepatitis or AIDS , tuberculosis .No history of trauma and operation. No history of hypersensitivity of any drug or food.Review of Systems:Respiratory system: no history of chronic cough , expectoration, hemoptysis , chest pain , or short of breath.Circulation system: no history of dyspnea or edema at the lower limbs. No history of palpitation or chest pain. No dizziness, headache, No history of hypertension.Digestive system: no history of anorexia, abdominal distention, regurgitation. No nausea and vomiting. No history of constipation , diarrhea ,melena and so on.Urogenital system: no history of swollen eyelids or lumbago. No frequent micturition, urgency of micturition or urodynia. No dysuria ,hematuria or retention and incontinence of urine .no history of acute or chronic nephritis.Hemopoeltic system: No pallid countenance ,weakness,dizziness , daze ,tinnitus. No history of bleeding and repeated infections. No history of enlargement of liver and spleen.Metabolic and Endocrine system:no abnormal cold or hot feeling, hidosis ,headacheweakness,impaired vision,polyphagia ,polyuria ect.normal distributed hair.no change of temper and intelligence.Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal sensation or motion. No change of personality .no mania ,depression or hallucination. Motor system: lumbago and limitation of movement for 2 years. weakness and numbness at lower limbs, the left more severe. No spasm, atrophy or palalysis. No joint red swollen, hot ,pain or limitation of motion. No trauma or fracture.Personal history: born in her native place and living in Tianjin. No history of exposure to poison.No habits of drinking or smoking.Marital History:. Married at 24 years old and having a child. the child and his wife both health.Family history: denying the family history of any heredity diseases ,or MD, CAD, hypertension ect.Physical ExaminationTemperature: 36.5°C pulse rate: 72/min respiratory rate: 18/min blood pressure:130/80mmHgGeneral appearance : normal development and medium in nourished ,no abnormal consciousness, good corporation in examination. Free position.Skin and mucous membrane : No pallid , cyanosis, and jaundice . no abnormal pigmentation and depigmentation . no erythma annulare, petechia and spider angioma. Normal elasticity of skin, no edema.Superficial lymph nodes: no enlargement of the superficial lymph nodes.Head and its organs:Skull: no deformity, tenderness or mass. Evenly distributed hair with black color and shine. Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids. No pallor, granules ,follicles pectechiae of conjunctivae . transparent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization. No exophthalmos or enophthalmos.free motions of the eye balls in any direction. Equal and round pupils at both sides with diameter 4mm, normal and active direct and indirect light reflexs,normal accommodation and convergence reflexes. Vision , visual field and eyegroud not examined.Ears:no deformity .no abnormal secretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.Nose: no deformity. No deviation of septum nasi. No ala flutter. No edema ,abnormal secretion ,and congestion of the membrane . good ventilation. No tenderness in any paranasal sinuses.Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth, no caries. No bleeding or congestion ,lead line in gums. Thin and slight yellow fur coated on the tongue ,with normal in motion. No redness and congestion in pharynx ,no deviation of uvulae. No edema in tonsils. Neck: symmetry . no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins. No rigidity .no enlargement of thyroid glands ,and the trachea in the centeral position. No murmur. Negative of hepatojugular reflux.Chest: symmetry. No deformity. No barrel chest ,pigeon chest or funnel chest. No tenderness overthe chest .the thoracic respiration present. R 18/min, symmetry in both sides. Symmetry and no abnormality of the 2 breasts.Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration. Respiratory movement equal in both sides and regular . no dyspnea or three concave sign.Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus. No pleural friction fremitus . no subcutaneous crepitation.Percussion: resonance in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th ,8th ,10th on midclavicular ,midaxillary,midcapular line respectively. The movement of the lower margin of the lungs: 6 cm..Auscultation: clear of vesicular breathing sounds all over the lung fields. No moist rales or rhonchis .normal of vocal resonance. No pleural friction sound.Heart:Inspection: no precordial bulging. Apical impulse in the 5th ICS 1cm inside of left midclavicular line with an area of 2 cm in diameter.Palpation: apical impulse and its area as that in inspection. Regular ,normal intensity. No pericardial friction rubs or thrill.Auscultation: HR 72/min with regular rhythm, heart sounds clear and intensive . no murmurs at any auscultation area of the valvula. No pericardical friction sound.Radial arteries: pulse rate 85/min, with regular rhythm, equal in both sides, normal intensity . Perivascular signs: no capillary pulsation, water hammer pulse ,pistol-shot sounds and Duroziez’s murmur . no pulse deficit, and pulse alternant.Abdomen:Inspection: symmetry. No bulge abdomen ,abdominal distention .normal abdominal respiration. No visible gastrointestinal waves. No varicosity , scar ,petechia at the abdominalSkin.Palpation: soft, no tenderness and rebounding tenderness, no tightened abdominal wall. No palpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphy’s sign.Kidneys: not palpable. No tenderness in the any site of kidneys or ureters.Spleen: not palpable.Appendix: no tenderness at the Mcburney’s site.Percussion: tympany in all over the abdomen, no shifting dullness. No percussive pain of liver and spleen. The upper margin of liver at the 5th ICS in the right midcalvicular line Auscultation: normal borhorygmus, 4/min, no murmur of vessels. No friction rubs .Anus and rectum: not examined.Spine: no lordosis, kyphosis, or scoliosis. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skin. Extremities: symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.myodynamia of left lower limb in 4th grade and right lower limb in 5-th grade. Details in the special condition.Nerve system:numbness in lower limbs ,more severe in left side. Normal sensation.at other place. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle clonus.Laboratory findings:Blood routine: WBC 7.3*10ª ,N 0.65, L 0.35,Hb 141g/l .RBC 4.38*1012/l ,plt 238*10ª/l. X-ray: hypertrophy of lumbar vertebrae.MRI : the results not gotten.Special condition:no lordosis, kyphosis, or scoliosis of spine. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skins. extrmities symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.Muscular tension of left lower limb in 4th grade and right lower limb in 5-th grade. Sensation in left lower limb decreased. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle segue sign(+).SummaryThe patient named Zhanghou ,male ,is 31 years old,admission with the chief complaint of lumbago for 2 years with weakness and numbness in the lower limbs, more svere for 2 months.2 years ago ,after working ,the patient always felt lumbago, sometimes referred pain at the hip and lower extremities,mainly at the dorsal side.and the left lower limb was more severe. At the same time he felt weak and numb at lower limbs, also more severe in the left side. No muscle atrophy, no abnormal of stool and urine. No temperature abnormal or color changes in the local skin. No nails damaged. Then the patient went to the hospital in his town, and had a X-ray examination, shown hypertrophy in the lumbar vertebrae., given some drugs for pain-control. After having some drugs and more rest, the symptoms lightened. But 2 months ago ,without significant causes,the symptoms became more severe. The lumbago often made him sleepless at nights. And he can only walk 500 meters without a break. his left lower limb felt numb and weak.Having the drugs and rest both can not ease the symptoms. So he came to our hospital for advanced diagnosis and treatment. Since the disease, no changes in consciousness,body temperature, appetite, body weight .and normal of stool and urine.PE: T:36.5°C, Bp 130/80mmHg,normal development, moderately nourished, clear counsciousness. Good corporation in physical examination. Normal in skull ,neck,lungs ,heart and abdomen no lordosis, kyphosis, or scoliosis of spine. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skins. extrmities symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.Muscular tension of left lower limb in 4th grade and right lowerlimb in 5-th grade. Sensation in left lower limb decreased. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle segue sign(+). Blood routine: WBC 7.3*10ª ,N 0.65, L 0.35,Hb 14.1g/l .RBC 4.38*1012/l ,plt 238*10ª/l.X-ray: hypertrophy of lumbar vertebrae.MRI : the results not gotten.Impression:Intern doctor :Bianbo此文档是由网络收集并进行重新排版整理.word可编辑版本！。

住院病历的英汉对照

住院病历的英汉对照•[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 lo calized 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) theleft 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 ofclots]▲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) vaginalbleeding]▲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 andlasted 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 ofmembranes)]▲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[***ual disorder]▲性变态[paraphilia]▲性要求高（低）[be over***ed(under***ed)]▲性感不快[dypareunia]▲性欲亢进（减退）[hyper***uality (hypo***uality)]▲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)]第四章过去史、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) sinc e 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 (***ual 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 fav oritism to, be partial to, like)]第五章月经、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）[***ual 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 illnessof 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……]第六章体检（一般项目）[Physical examination(general items)] •视诊[inspection]•触诊[palpation]•叩诊[percussion]•听诊[auscultation]•嗅诊[olfactory examination]•浅（深）触诊法[light (deep) palpation]•深部滑行（深压，双手，冲击）触诊法[deep slipping (deep press,bimanual,ballottement]•间接（直接）叩诊[indirect (direct) percussion] •叩诊音（过清音，清音，浊音，鼓音，实音）[percussion sound(hyperresonance,resonance,dullness,tympany,flatnes s)]•用钟（膜）型胸件听诊[with the bell (diaphragmatic) chestpiece ]1、体温[temperature, T]•口（腋、肛）温[oral (axillary, rectal) temperature] •经口（腋、肛）测的温度[per mouth (axilla, rectum)] •摄氏与华氏换算[Centigrade VS Fahrenheit]℃=5/9(℉-32)℉=9/5℃+32℃～℉℃～℉36.5～97.7 38.5～101.337.0～98.6 38.9～102.037.2～99.0 39.0～102.237.5～99.5 39.4～103.037.8～100 40.0～104.038.0～100.4 40.5～104.938.3～101.0 41.0～105.8•37.5℃.orally(99.5℉)[口温摄氏37.5度（华氏99.5度）]2、脉搏[pulse, P]•脉率72次/分[pulse 72 beats per minute(P 72 bpm)]•搏动存在（消失）[pulse are present (absent)] •速（缓）脉[fast (slow) pulse]•洪（细丝）脉[bounding (small, thready) pulse] •水冲脉[water hammer pulse]•交替脉[alternating pulse]•奇脉[paradoxical]•二联（三联）脉[bigeminal (trigeminal) pulse] •重脉[dicrotic pulse]•间歇脉[intermittent pulse]•陷落脉[collapsing]•不规则（规则）脉[irregular(regular) pulse]3、呼吸[respiration, R]•呼吸频率[respiratory rate (RR)]•呼吸频率19次/分[RR 19 beats/min (R 19 bpm)] •规则（不规则）呼吸[regular (irregular) breathing] •呼吸均匀[eupnea]•呼吸急促（缓慢）[repid (slow) breathing]•呼吸停止（中断）[pausal (interrupted) breathing] •呼吸骤停[breath arrest]•深（浅）呼吸[deep (superficial) breathing]•呼吸困难[dyspna (short of breath)]•呼吸费力[labored breathing]•胸（腹）式呼吸[thoracic (abdominal) breathing] •张口呼吸[mouth (buccal) breathing]•周期性呼吸[periodic respiration]•库斯毛氏呼吸[Kussmaul`s respiration]•陈-施（潮式）呼吸[Cheyne-Stokes (tidal) respiration]•间歇呼吸[Biot`s breathing]•叹息样（胎儿,鼾样）呼吸[sighing (fetal, stertorous) respiration]•口臭[have foul (fetid) breath (halitosis)]•酮味呼吸[a smell of ketone] •静息下（活动时）气促[dyspnea at rest (on exertion)]•丙酮（氨臭，蒜臭）味[acetone (ammoniacal, alliaceous) odor]•肝臭[hepaticus fetor]•腋臭[bromidrosis]4、血压[blood pressure, BP]•收缩（舒张）压[systolic (diastolic) blood pressure] •血压20/12千帕（150/90毫米汞柱）[BP 20/12 kPa(150/90mmHg)]1kPa=7.5mmHg (1mmHg=0.1333kPa)•血压为收缩压20，舒张压12千帕[Bp is 20 over 12 (Bp is 20 systolic and 12 diastolic)]•测量血压[take (measure, check ) Bp]•坐（卧）位血压[sitting (lying) Bp]•无创（有创）血压[non-invasive (invasive) Bp] •脉压[pulse pressure]•血压测不出[Bp is unavailable (unobtained)]•左臂（右臂）血压[Bp in left (right) arm]•双下肢血压[Bp in both lower limbs]•袖带[cuff]5、体位[position]•主动（被动、强迫）体位[active (passive, forced ) position]•立（坐、卧）位[upright (sitting, dorsal) position] •仰卧（俯卧）位[supine (prone) position]•左（右）侧卧位[left (right) lateral (decubitus) position]•蜷腿位[coiled position]•半卧位[semi-reclining (semi-recumbent) position] •端坐位[orthopnea position]•胸膝（膝肘）位[knee-chest (knee-elbow) position] •截石（分娩）位[dorsosacral (obstetric) position] •角弓反张位[opisthotonus position]•强迫蹲位[compulsive squattin]•辗转体位[alternative position]•头高（低）脚低（高）位[high (low) head and low(high) legs]6、神志和意识[consciousness and mind]•清醒（半清醒的）[alert (semi-conscious)]•昏迷（半昏迷）的[comatose (semi-comatose)] •无精打采的[listless]•思睡的[somnolent (drowsy, sleepy)]•昏睡的[lethargic]•焦虑不安的[anxious (restless, apprehensive)]•激动的[excited (irritable)]•精神错乱的[confused]•意识障碍[distrubance of consciousness]•谵妄[delirium]•抽搐[convulsion]•木僵的[stuporous]•合作佳（欠佳、差）[cooperation is good (not good enough, bad)]•反应迟钝[have a dull reaction]•有（无）定向力[be oriented (disoriented)]•朦胧状态[be in a mist tent]•神志模糊[blurred (dim, vague) mind]•失去知觉[loss consciousness(unconsciousness)] •对疼痛刺激的反应[reaction to painful stimuli] 7、面容[facial features]•呈急（慢）性面容[be in acute (chronic) distress] •病然面容[critical facies]•濒死面容[hippocratic facies]•苦笑面容[sardonic facies]•表情不安[anxious (distressing) expression]•神情憔悴[ haggard expression]•贫血（肾病、肝病）面容[anemic (nephrotic, hepatic) facies]•二尖瓣（伤寒）面容[mitral (typhoid) facies] •满月（面具）面容[moon (masked) facies]•肢端肥大症面容[acromegaly facies]•甲亢（粘液性水肿）面容[hyperthyroid (myxedema) facies]•老年貌[senile feature]•颜面潮红（苍白）[reddy (pale) facies]•面色红润[florid facies]8、发育[development]•身高[body height (length)]•身材（高大、矮小）[stature (tall, dwarf)]•体格（强壮、脆弱）[physique (strong, weak)] •青春期[adolescent spurt]•体型[habitus]▲无力（乏力、超力）型[asthenic (ortho-sthenic, sthenic) type]▲巨人症（重体侏儒症、奄人症）[gigantism (pituitary dwarfism, eunuochism)]▲运动员体型[athletic type]▲矮胖（瘦长）型[stocky (lanky) type]•一位发育良好（中等）的病人[a well (middle)-developed patient]•发育不良（异常）[hypoplasia (dysplasia)]•身高171厘米[177cm in height]9、营养[nutrition]•营养良好（中等、不良）[well (middle, under)-nourished]•良好、不良，中等[well (poorly, fairly)]•肥胖[obesity (overweight,fat)]•消瘦[emaciation (underweight, thin, lean)]•恶液质[cachexia]•水牛背[buffalo hump]10、姿势与步态[posture and gait]•共济失调步态[ataxic (incoordination) gait]•剪刀步态[scissors gait]•慌张步态[festinating gait]•跨域步态[steppage gait]•摇摆步态[swaying gait]•蹒跚步态[reeling (staggering, waddling) gait]•闭目难立征[Romberg`s sign]•间歇性跛行[intermittent claudication]11、皮肤与粘膜[skin and mucosa]▲颜色[color]▲苍白（红色、暗红、潮红、粉红色）[pallor (redness, dusky redness, flush, pinky)]▲显得苍白[be (look) pale]▲紫绀（手足发绀）[cyanosis (acrocyanosis)]▲黄疸（黄染）[jaundice (stained yellow)]▲黑色素[melanin]▲色素沉着过多（减退）[hyper pigmentation (depigmentation)]▲色素沉着增加(减少)[pigmentation increase （decrease）]▲白癜（白斑）[vitiligo (leukoplakia)]▲雀斑（老年斑）[fleck (senile plague)]▲紫（妊娠）纹[purple (pregnant) striae]▲多血症[be plethoric]▲重度（中度、轻度）紫绀[be severely (moderately, slightly) cyanosis]•湿度与弹性[moisture and elasticity]▲干燥（湿润）的[dry (moist)]▲湿冷[cold moist]▲冷（暖、热）[cool (warm, hot)]▲光滑（粗糙）的[smooth (rough)]▲光亮的[shing] ▲紧张（松弛）的[taut (loose)]▲软（硬）[soft (hard)]▲鳞状（皱纹）的[scaly (wrinkling)]▲有（无）弹性的[elastic (inelastic)]▲萎缩（肥厚）的[atrophic (hypertrophic)]▲皮下气肿[subcutaneous emphysema]▲全身（局限）性水肿[anasarca (localized edema)] ▲凹陷性（非凹陷性）水肿（加重、减轻、消退）[pitting (non-pitting) edema (increase, decrease, subside)]•皮损[skin lesions]▲皮疹[skin eruption]▲斑疹[maculae]▲玟瑰疹[roseola (rose spots)]▲丘疹[papule]▲斑丘疹[maculopapule]▲风疹[rubella]▲疱疹[belbs]▲斑片[patch]▲斑块[plaque]▲荨麻疹[urticaria (hives)]▲脱皮（屑）[desquamation (excoriation)]▲蜘蛛痣[spider angioma]▲皮下小结[subcutaneous nodules]▲瘢痕[scar]▲痱子[sudamen]▲水（血、脓）疱[water (blood, pus ) bpister]▲小（大）水疱[vesicle (bulla)]▲单纯疱疹[herpes simplex]▲风团（囊肿、肿瘤）[wheal (cyst, tumor)]▲皮屑（鳞屑）[furfur (scale)]▲结痂（焦痂）[crust (eschar)]▲溃疡（糜烂、皱裂）[ulcer (erosion, fissure)]▲肝掌（朱砂掌）[liver (erythema) palms]▲黄褐斑[chloasma]▲环形红斑[circinate erythema]▲黑痣[pigmented nevas]▲胎记[birthmark]▲疣（鸡眼）[werruca (clavus)]▲冻疮[pernio]▲褥疮[bedsore (decubitus)]▲渗液[exudate]•出血[bleeding]▲瘀点[petechia]▲紫癜[purpura]▲瘀斑[ecchymosis]▲血肿[hematoma]▲片状出血[splinter hemorrhage]▲渗血[oozing of the blood]▲压之褪色[blanch on pressure]12、头发与指甲[hair and nail]•头发（稀疏、浓密、秃头）的[hair (sparse, dense, bald)]•头皮[scalp]•粗（细）[coarse (fine)]•密（疏）[thick (thin)]•干性（油性）[dry (oily)]•有（无）光泽的[lustrous (lusterless)]•多（少、无）毛[hairy (oligotrichosis, hairless)] •脱发（斑秃、全秃）[hair loss (alopecia areata, baldness)]•眉毛（阴毛、腋毛）稀少（过多）[scant (excessive) eyebrows (public hair, axillary hair)]•体毛（胡须）[body hair(beard) ]•全身性多毛症[hypertrichosis universalis]•毛发的性状和分布[quality and distribution of the hair]•甲变形（匙状甲）[deformities of nail (spoonnail)] •薄（脆）甲[thin (brittle) nail]•甲脱落[ongchoptosis]13、浅表淋巴结[superficial lymph nodes]•浅表淋巴结未扪及[be no palpable superficial lymph nodes (…can not be palpated)]•淋巴结肿大[enlarged lymph nodes (lymphnode enlargement)]•部位[site]▲全身（局部）[general (local)]▲耳前（后）淋巴结[pre(post)-auricular nodes]▲枕后淋巴结[occipital nodes]▲颏下淋巴结[submental nodes]▲下颌淋巴结[submaxillary nodes]▲颈前（后）淋巴结[anterior (posterior) cervical nodes]▲ 锁骨上淋巴结[supraclavicular nodes]▲滑车上淋巴结[epitrochlear nodes]▲腋窝上（内侧，前，后，外侧）淋巴结[axillary top (medial,anterior,posterior,lateral)]▲腹股沟淋巴结（横组，纵组）[inguinal nodes (transverse group,longitudinal group) lymphnode] •大小[size]▲4×2cm大小[4 by 2 cm in diameter (size)]▲米粒（豌豆，核桃，小指，拇指，拳头，手掌，鸡蛋）大小[size of a rice grain(pea,walnut,small,ringer,thumb,fist,palm,hen’s egg)]▲针头大小[pinhead size]▲苹果大小[size of an apple]▲小孩头（成人大小）[size of a infant’s(man’s) head]•形态[shape]▲不规则[irregular]▲结节（颗粒、纺锤）状的[tuberous (granular,spindle-shaped)]▲光滑（粗糙）的[smooth (coarse)]▲平坦（凹凸不平）的[flat (uneven)]▲球（椭园，卵园，园）形的[globular (elliptical,oval,circular)]•硬度和活动度[hardness and mobility]▲硬（软）[hard (soft)]▲石头（骨）样硬[of stone-like (bone-like)]▲可活动（固定）的[movable (fixed)]▲与周围组织（结构）固定[be fixed to the surrounding tissues (structures)]▲压痛[tenderness]▲融合（粘连）[fusion (adhesion)]▲肿胀（疤痕）[swelling (fistula)]第七章体检（头颈部）[Physical examination(head and neck)]1、头颅[cranium,skull]•头颅变形[deforming skull]•头形（围）[head contour (circumference)]•小颅（尖颅，巨颅）[microcephalism (acrocephalia,large skull)]•长（短）头[dolichocephalia (brachycephalism)] •方（塔）颅[squared (tower) skull]•落日现象[sitting sun phenomenon]•颅缝[cranial suture]•前（后）囟门[anterior (posterior) fontanel]•囟门膨出（塌陷）[bulging (edpressed) fontanel] •囟门晚（早）闭[delayded (earlier) closure of the fontanel]2、眼球[eyeball] •眼球浮动[ocular bobbing]•眼球破裂[eyeball rupture]•眼球穿孔伤[ocular-perforating injury]•眼球内异物[intralcular foreign body]•眼距增宽（变窄）[ocular hypertelorism (hypotelorism)]•眼球萎缩[atrophy of eyeball]•眼球突出（凹陷）[exophthalmos (enophthalmos)] •眼球震颤[nystagmus]•眼球固定[eyeball fixation (stare)]•眼球活动受限[limitation of eye movement]•假眼[ocular prosthesis]•眼外肌运动[extraocular movements]3、眼睑[eyelids]•睑内（外）翻[entropion (ectropion)]•流泪[lacrimation]•上睑下垂[ptosis]•眼睑痉挛（松驰）[blepharospasm(blepharo-chalasis)]•眼睑水肿（红肿）[edema (redness and swelling) of the eyelids]•瞬目过少[nictitation diminution(lid lag )]•瞬目过多[frequent nictitation (blinking)]•眼裂缩小（增宽）[blepharophimosis (blepharodia stasis)]•眼睑充血[blepharal hyperemia]•泪囊[lacrimal sac。

病历常见英文缩写及中文释义对照表之欧阳道创编

病历常见英文缩写及中文释义对照表AA 白蛋白（单位g/L）AA 再障AB实际碳酸氢盐ABG动脉血气ACEI血管紧张素转换酶抑制剂ACT激活凝血时间AD 阿尔海默茨病Af房颤AFP 甲胎蛋白定量（单位ng/ml）AG离子间隙AGN 急性肾炎a-HBD a-羟丁酸（单位U/L）AI 主闭AIHA 自身免疫性溶血性贫血AIH 自身免疫性肝炎AIN 急性间质性肾炎AKP 碱性磷酸酶（单位u/L）ALT 谷丙转氨酶（单位u/L）ALT 成人T细胞白血病AMI 急性心梗ANA 抗核抗体AP 心绞痛AP 急性胰腺炎DU十二指肠溃疡APB 房早APOA-1 载脂蛋白A1（单位mg%）APOB-100 载脂蛋白B100（单位mg%）APTT活化部分凝血活酶时间（单位秒）ARDS急性呼吸窘迫综合征ARF 急性肾功能不全AS 主狭ASD 房缺ASO抗链球菌溶血素“0”ASO 闭塞性动脉硬化AST谷草转氨酶（单位u/L）AT 房速ATP三磷酸腺苷A VB 房室传导阻滞A VNRT房室结折返性心动过速A VRT房室折返性心动过速BBabinski征指锥体束病损时大脑失去了对脑干和脊髓的抑制作用而出现的异常反射BB缓冲碱BBB 束支传导阻滞BE 碱剩余（单位mmol/L）BEE基础能量消耗BIL 胆红素Bicarbonate 碳酸盐BLO 潜血BP血压BS空腹血糖（单位mmol/L）BT出血时间BUN尿素氮（单位mmol/L）CC 反应蛋白（单位vg/ml）Ca 钙CAP 社区获得性肺炎CBC全血球计数CCU心血管监护室CEA 癌胚抗原（单位vg/ml）（辅助恶性肿瘤诊断）CF 心衰CGN 慢粒CGN 慢性肾炎CHD冠心病CHE胆碱酯酶CHF 充血性心衰CIN 慢性间质性肾炎CK 肌酸激酶（单位U/L）CK-MB 肌酸激酶同工酶（单位U/L）CL 氯化物（单位mmol/L）CLL 慢淋cm 厘米COPD 慢性阻塞性肺气肿CO2Cp 二氧化碳结合力（单位mmol/L）CPAP持续正压通气CPR心肺复苏Cr 肌酐（单位vmol/L）CRF 慢性肾功能不全CT 凝血时间（单位秒）CT断层扫描CVP中心静脉压C3补体C3（单位mg/ml）（降低见于急性肾炎）C4补体C4（单位mg/ml）（降低：见于免疫复合物引起的肾炎、系统性红斑狼疮、病毒性感染、狼疮性症候群、肝硬化、肝炎等）DD-BIL直接胆红素（单位vmol/L）DBP舒张压DCT双氢克尿噻DIC弥散性血管内凝血DKA 糖尿病酮症酸中毒DLE 盘状红斑狼疮DM舒张期杂音DM 糖尿病DN 糖尿病肾病DR 糖尿病视网膜病变ds-DNA 抗双连DNA抗体EEF射血分数ENT耳鼻喉科(五官科)ERCP 内镜逆行胰胆管造影术ESR 血沉（单位mm/h）E3VtM4格拉斯哥评分等级中的一种FFD 功能性消化不良FDP纤维蛋白原降解产物Fe 铁（单位mol/L）FUO不明原因发热F3 法三F4 法四GG 球蛋白（单位g/L）GD 甲亢GravesGERD 胃食管反流病g/L克/升GLASGOW-Ⅱ/gcs格拉斯哥昏迷评分GLU 葡萄糖/尿糖GNS葡萄糖生理氯化钠溶液GRA中性粒细胞（单位%）GU 胃溃疡HHAP 医院获得性肺炎Hb血红蛋白HbCO碳氧血红蛋白HBsAg乙肝表面抗原HGB血红蛋白浓度（单位g/L）HCO3碳酸盐（单位mmol/L）HCT 红细胞压积（单位%）HD 霍奇金病HDL 高密度脂蛋白（单位mg%）HE 肝性脑病HIE 新生儿缺血缺氧性脑病HIV人类免疫缺陷病毒HNKHC 高渗性非酮症糖尿病昏迷Hoffmann征上肢的锥体束征Holter24h动态心电图IIABP主动脉内气囊反搏术IBD 炎症性肠病I-BIL间接胆红素（单位vmol/L）IBS 肠易激综合症IDA 缺铁贫IDD 胰岛素依赖性糖尿病IgA免疫球蛋白A（单位/L）IgG免疫球蛋白G（单位/L）IgM免疫球蛋白M（单位/L）IGT 糖耐量减低IHD 缺血性心脏病IHSS特发性肥厚型主动脉瓣下狭窄IIM 特发性炎症性肌病INS胰岛素（单位IU/L）INR国际标准比率IPF 特发性肺纤维化ITP 过敏性紫殿IU国际单位IU/L 国际单位/升KK 钾（单位mmol/L）Kernig克尼格氏征，简称克氏征，是神经科常用的一种检查方法检查方法KET 酮体KPTT部分凝血活酶时间KUB腹部平片抗HBs乙肝表面抗体抗HBee抗体抗HBc核心抗体注:其中抗HBs、抗HBe为有益指标；抗HBc提示正在复制或既往已感染而现在已停止LL升Lac乳糖Large(+++)LD 低密度脂蛋白（单位mg%）LDH 乳酸脱氢酶（单位U/L）LEU 白细胞Ly% 淋巴细胞比值（单位%）Ly 淋巴细胞计数（单位109/L）LYM淋巴细胞（单位%）MMAS或POED 多发性骨纤维结构不良MCH 平均红细胞血红蛋白含量（单位pg）MCHC 平均红细胞血红蛋白浓度（单位g/L）MCV 平均红细胞体积（单位fL）MDS 骨髓增生异常综合症MG 重症肌无力mmHg（毫米汞柱）mmol/L（毫摩尔/升）MI 心梗MID单核细胞（单位%）MM 多发性骨髓瘤Moderate(++)MONO% 单核细胞比值（单位%）MPV平均血小板容积（单位fl）MVP 二间瓣脱垂NN%中性粒细胞比率Na 钠（单位mmol/L）nCa游离钙（单位mmol/L）Negative (-)NEUT% 中性粒细胞比例（单位%）NHL 非霍奇金NIT 亚硝酸盐NS生理氯化钠溶液NTG硝酸甘油OOB隐油OX2一种伤寒变形菌，具体名称不详OX19 斑疹伤寒OXk恙虫病PP 磷（单位mg/dl）PLT血小板计数（单位109/L）Pa02氧分压（单位mmHg）PaCO2二氧化碳分压（单位mmHg）PCO2二氧化碳分压PLTPH酸碱度PRO 蛋白质PT 凝血酶原时间测定（单位秒）Positive 阳性PY 蛋白定量（单位g/L）P(A-a)O2肺泡气-动脉血氧分压差P2肺动脉第二心音PaCO2动脉二氧化碳分压PAMPA氨甲苯酸PaO2动脉氧分压PCAP肺小动脉压PCWP肺毛细血管压PEEP呼气末正压pH酸碱度PPD结核菌素纯蛋白衍生物Prn必要时PT凝血酶原时间PAP 肺泡蛋白质沉积症PIE 间质肺气肿PTE 肺栓塞PCP 卡式肺囊虫肺炎PDA 动脉导管未闭PS 肺狭PAT 阵发性房性心动过速PNH 阵发性睡眠性血红蛋白尿PKU 苯丙酮尿症PD 帕金森氏病PEM 蛋白质－热能营养不良PID 盆腔炎Qqh每小时1次qid每天4次qn每晚1次qod隔日1次RRRBC 红细胞计数（单位1012/L）r-T3 反T3（单位ng/ml）r-GTr-谷氨酰胺转酞酶（单位u/L）RF类风湿因子RI胰岛素RR呼吸频率RBBB 右束支传导阻滞RAEB 难治性贫血伴原始细胞增多型RA 类风湿关节炎SSP02ScrSBESG 比重Small(+)S3第3心音S4第4心音SaO2血氧饱和度SB标准碳酸氢盐SBE亚急性细菌性心内膜炎SBP收缩压SGOT血清谷草转氨酶SGPT血清谷丙转氨酶SK链激酶SM收缩期杂音SSS 病态窦房结综合症SBE 亚急性感染性心内膜炎SAP 急性重症胰腺炎SSc系统性硬化病SLE 系统性红斑狼疮SCA 脊髓小脑共济失调TTTBIL/ T-BIL 总胆红素（单位vmol/L）TT凝血酶时间测定（单位秒）Trace(±)TTT 麝香草酚浊度实验（单位u）TBA胆汁酸（单位vmol/L）TP 总蛋白（单位g/L）T-CH总胆固醇（单位mg%）TG甘油三脂（单位mg%）TSH促甲状腺素（单位vIU/ml）T3三碘甲状腺原氨酸（单位ng/ml）T4甲状腺素（单位ng/ml）TPN全胃肠外营养T3三碘甲状原氨酸T4甲状腺素TAT抗蛇毒血清TIL短暂脑缺血发作tid每天3次t-PA组织型纤溶酶原激活物TPN全肠道外营养TSH促甲状腺激素TB 肺结核TIP 血栓性血小板减少性紫殿T2DM 2型糖尿病UU/L单位/升URO 尿胆原UA血尿酸（单位mmol/L）UK尿激酶UA 不稳定性心绞痛UC 溃疡性结肠炎VVLOL 极低密度脂蛋白（单位mg%）V/Q通气/灌注比VMA香草基杏仁酸VSD 室缺VDH 心脏瓣膜病WWBC白细胞计数（单位109/L）WD 肝豆状核变性其他µg/kg.min（微克/千克*分钟）µmol/L（微摩尔/升）。

病历中中英文对照

病历中中英文对照第一章病人身份[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 age2、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`scolleague] 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)] 一般第二章主诉[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 (Sputum hlegm)] 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] 妄想第三章现病史[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。

病历中英文对照

中文：描述平扫见胸椎生理性弯曲存在，诸椎体及附件大小、形态及信号正常各椎间盘形态、大小、和信号未见异常，Th2-Th3节段椎管内脊髓背侧偏右侧可见不规则结节样混杂信号影，局部椎管狭窄，胸髓受压，信号无异常发现，椎旁软组织无特殊。

各扫描层面见各小关节正常。

Th10节段椎管内黄韧带局部呈小结节样低信号影（黄韧带钙化？）。

增强扫描显示Th2-Th3节段椎管内脊髓背侧偏右侧病变出现明显不规则结节样强化影，邻近脊膜出现条状强化影。

译文：Findings:Non-contrast enhanced MRI showed physiological curve of thoracic vertebrae. No abnormality was identified in the size, shape and signal intensity of the vertebral body, its annexa, and intervertebral discs. Irregular, mixed and nodule-like signals were observed in the dorsal spinal cord (deviation to right) in the spinal canal of T2~3 levels. Local spinal stenosis was noted together with compression of the thoracic cord. No abnormal signal was identified in these parts. Additionally, no abnormality was found in the paravertebral soft tissues. No abnormality was noticed in the facet of each scanning plane. Small nodule-like, low-signal shadow was observed in the local ligamentum flavum within the vertebral canal of the T10 level. Then calcification of ligamentum flavum was suspected. Contrast enhanced MRI indicated obvious, irregular, nodule-like enhanced shadow in the dorsal spinal cord (deviation to right) in the spinal canal of T2~3 level. Also, enhanced shadow in a strip pattern was noted near the spinal meninges.。

住院病历中英文对照

1 ( )表格式住院病历2 :一般项目：3姓名年龄性别婚否籍贯民族4职业入院日期病史叙述者病史5主诉6现病史既往史：7 : 平素健康状况：良好一般较差传染病史8 : N Y 预防接种史过敏史无有临床表现9: : :过敏原外伤史手术史10: ( , . , )系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过)11 :呼吸系统12 咽痛慢性咳嗽咳痰咯血哮喘13呼吸困难胸痛14 :循环系统15心悸活动后气促咯血晕厥163 m4 G: a6 ] h下肢水肿心前区疼痛高血压 :消化系统; L. N) e w!A$ H* W食欲减退反酸嗳气恶心呕吐8 G1 d;P$ `( ]腹胀腹痛便秘腹泻8t) }/ q7 i' ]6 V c2 ^) i9 h呕血黑便便血黄疸:泌尿系统腰痛尿频尿急尿痛7 D) {2 ?5 L9 L V9 G排尿困难血尿夜尿多尿少尿面部水肿造血系统乏力头昏牙龈出血"j9 w, N. P5 j m! C' z$ {% i; V4 r7 {- S皮下出血骨痛鼻衄0b* ?5 ] ~ R* b( A"g e* H:代谢及内分泌系统食欲亢进食欲减退多汗畏寒" f8 X: \! j |4A r6 z0 [: z) L! {+y$ l多饮双手震颤性格改变显著肥胖* D* N. | ]- E. ^% k" v5 ]6 A* g消瘦多毛毛发脱落色素沉着: N d4 x! B5 R性功能改变闭经. T' J. A; Y, ]2 f- \+ }/ L6 H8 e8 A9 H; {# G肌肉骨骼系统 2 G1 W5 f1 z B游走性关节痛关节痛关节红肿! f7 T4 \% p; e. ^; n关节变形肌肉痛肌肉萎缩0 J8 Y( x1 f, O1 o9 ^神经系统: t0 N! C' {/ w, b" j头昏头痛眩晕晕厥记忆力减退# I4 M6 l视力障碍失眠意识障碍4 V6 W* m2 L; k颤动抽搐瘫痪感觉异常 :5 f( t5 O) p8 ]个人史N Y 4 ]% S6 l7 e; O* u;g) c3 B出生地职业冶游史吸烟无有) z' c! [2 C9 h( \0 c约年平均支/日戒烟年* b0 V6 ]/ z a5 IN - x M4 u w1 X1 c. x嗜酒无偶有经常约为年1 ^( i; Q7 l平均日其他) Y4 x. U( D:婚姻史：, {0 t( o, A, ^8 g3 l’s : x5 z. E8 X) W5 M! Q* t结婚年龄配偶健康状况6 d9 R1 x5 p9 |1 | :7 ?) }9D月经及生育史( a0 C* i9 z5 l* A2 @' p! q' s, t: D; E初潮每次持续时间末次月经时间( )绝经年龄. G$ \0 @5 x; ?" t: : N Y 经量少正常多痛经无有: ?1 D1 t8 u9 t( S7 q" s) q经期规则不规则妊娠次顺产$ b0 E4 k7 B, u胎流产胎早产胎' Z' h. _* K8 t) w B! D1 H6 p0 y, q" B6 z, W9 J死产胎难产及病情% w' U9 {: f) ~( ' N5 O5 Q g; _4 ?! N* F; `3 c! }/ c( T2 w家族史（注意与患者现病有关的遗传病和传染性疾病）3 L2 p4 s0 _ : : 父：健在患病已故死因母 : :健在患病已故死因兄弟姐妹子女其他8 [+ E( v2 e) e" b4 ~体格检查' _( P5 `0 F$ B5 p生命体征: ' | P( f" M0 W8 J体温4 p( \# Y' @" z,g3 b9 [脉搏次/分呼吸次/分/ O( V. |; t0 y. q2 [血压 B2 K) W8 I! l( L6 X一般状况:发育: 正常* Z3 t. N: ]+ A$ v0 \& @! s不良超常营养: . |$ W2 G* Z"I0 c$ }$ T9 s良好: b3 ]* R9 }2 T. \中等7 A( k0 d2 r( ^& Z( l不良0 O6 c8T9 a6 S" M恶病质6 e D7 A. m9 E! R面容: , N; _' T" p无病容急性" T, P9 u, Z:w6 ~慢性病容 3 D2 @9 U; h!t! N) Y$ X其他; i' P5 M9 L7 P; y表情: 自知% A0 j: p.n8 Z$ x1 g8 L) }痛苦' M3 K! p) q" ^0 _忧虑. w n, I4 O2 F3 Y* G$ G恐惧) ?' P) K2 G" i9 |$ W淡漠0 L' f3 h2 `) A6 e n) k R6 Y r: 体位：自主半卧位其他: & M; [" \9 k) `8 I步态正常不正常6 d: I5 w; K6 c8 m7 I: u( f L* g! ]- L' e, v9 J, u神志清楚嗜睡模糊昏睡昏迷; 2 A5 R8 y; L0 c谵妄配合检查合作不合作. F; M4 ]* z" I, `2 H: W( Y: " d D) _, t5 M. T r. z皮肤粘膜色泽无病容潮红苍白紫绀Y ( ); n3 c; k, n8 ?) E黄染色素沉着皮疹无有（类型及分布）. S$ t, a P. g7 Z* B1 [7 n: N Y( ) 6 t1 u8 |* j 皮下出血无有（类型及分布）: : N Y( ), ?0 H, o* k9 K头发分布正常减退水肿无有（部位及程度）0 v0 E3 R e* X k0 u: N Y Y（） }2 B3 N ]- C肝掌无有蜘蛛痣无有(部位数目) 其他:淋巴结8 ?* k' ^- @; ~; `7 }3 L: ( )" L, R" z! P. y* p0 F9 m全身淋巴结肿大无肿大肿大（部位及特征）3 M* U' k1 H! z! |6 H: : : : & R' k4 G"d y6 F头部头颅大小正常大小畸形N Y( )无有（尖颅方颅变形颅）/ `6 t4 [0 b8 N2 V) C8 N: J$ V6 e4 C. R: ()其他异常：压痛包块凹陷（部位）: : 眼睑正常水肿下垂倒睫结膜; A( L$ F: \+ S Z正常充血水肿出血 2 n u. |3 q8 e0 I: - e8 {# m, ^* Z, z; p" v眼球正常突出凹陷震颤( )运动障碍: ( )巩膜无黄染有黄染角膜正常异常（左右）5 W. R' Z; G1 ?7 E' t1 r2 ]: 瞳孔等圆等大不等左: ( ) ( ) 对光反射正常迟钝（左右）消失（左右）+ q: Z* j. b1 \ Q6 P: J7 y2 `, E) d其他: ( )) o4 I2 w9 u 耳耳廓正常畸形瘘管其他（左右）' y4 _3 U6 ~3 r: N Y ( )外耳道分泌物无有（左右性质）" s7 F3 F9 F4 u: N Y : N Y ( )* p( h7 l; b0 n3 B乳突压痛无有听力粗试障碍无有（左右）; O* @3 E: A3 C6 O2 S' U: : : ( ) Y " [+ D9 E7 o$ [1 _. u6 |鼻外形正常异常（）其他异常无有: ( y5 l ^$ I5 O鼻翼扇动鼻塞分泌物鼻旁窦压痛! }: g4 Z ? R$ q; O, {N Y ( )无有（部位）口唇红润发绀苍白疱疹皲裂粘膜正常) ]" D2 r4 A( )异常（苍白出血点）`. }" a1 r( H. X, s3 [: ( 腮腺导管开口正常异常（肿胀9 W) J* G7 R )脓性分泌物）( )) i2 S9 v, a( l7 Q" s舌正常异常（舌苔伸舌震颤向左、向右偏斜）: " b6 e. i4 G7 u$ y, s牙龈正常肿胀溢脓出血色素沉着铅线牙列齐缺牙—|—龋齿—|—) `+ l0 q' ]% o! n6 R: : : 扁桃体咽声音正常嘶哑2 [5 ?5 M: T2 X$ M; y: e Y : 颈部抵抗感无有颈动脉搏动正常增强( ) 减弱（左右）颈静脉正常充盈( )4 o( z0 ]4 v1 ]怒张气管正中偏移（向左向右）9 L" u$ S* n; g) (+) : 肝颈静脉回流征：（-）（+）甲状腺正常肿大度对称: Y 侧为主弥漫性结节性质软质硬其他无有) t9 _6 G5 t) s ( )（压痛震颤血管杂音）胸部胸廓正常桶状胸鸡胸漏斗胸; t3 d" i" Q" b( )扁平胸膨隆或凹陷（左右）7 L* A2 k5 i"a X7 j u8 _; x9 {0 S* E: Y: y. U心前区膨隆胸骨压痛" y( M7 L0 V9 j: : ( # v7 a, j, ^0 x* }( {乳房正常对称异常左右（男乳女化)1 V' k6 p0 {& l9 A) z0 [包块压痛乳头分泌物） T) x3 ~* ^% U" [0 }( C1 @, c, A病史记录者并使审阅者记录日期3r. n4 S5 B2 {3 A肺: : : ) P3 }5 |5 T6 w视诊呼吸运动正常异常左 1 r6 [) C3 c; L A( Y1 R ( )2 I7 |9 A; c5 K0 L0 L" $ m右（增强减弱）& R" S1 D3 L9 {/ L( I()肋间隙正常增宽变窄（部位）. ~$ O8 l0 ]' `5 X4 m: ( 2 n; o1 r$ ?1 [& V触诊：语颤正常异常左右（增强) : N Y（）7 p3 j9 a( k7 Z1 @减弱胸膜摩擦感：无有（部位）/ b" V @' B: S: N Y() : , ^" u$ E5 j5 J 皮下捻发感无有（部位）叩诊正常清音" U2 n3 k) i3 I$ U) P异常叩诊音浊音实音过清音鼓音! $ K' t; o8 Z: O V: k: , ! V8 c( a: s' O0 m' H肺下界肩胛线右肋间左8 o) O: R6 Q7 Z5 b. ?: , \4 R3 S( V' I5 g' t" d0 J肋间移动度右，左: 听诊呼吸规整不规整3 F5 R. y$ J; \7 ]: ( , )呼吸音正常异常（性质，部位描写）: N Y ：: 3 L; A4 l: j( m 啰音：无有：干性鼾音哨笛音 : 湿性大中小水泡音捻发音: : ()语音传导正常异常减弱增强（部位）: N Y ()胸膜摩擦音无有（部位）心6 f0 e$ ?3 l7 ?* B" W : N Y : 视诊心前区隆起无有心尖搏动: 9 y0 p7 d$ C0 z6 B5 c. _, j正常未见增强弥散心尖搏动位置正常- s8 H0 v!T2 J9 X( )移动（距左锁骨中线内外厘米）: N Y ()其他部位搏动无有（部位）; f: }. Z. _' v; z, K. m2 h) ~1 R X, T9 S触诊心尖搏动正常增强抬举感触不清4 L2 \( h( F' lY ( ) Y震颤无有（部位时期）心包摩擦感无有: ( )叩诊相对浊音界正常缩小扩大（右左）; x1 Q6 \- j2 s: ( 5 L* B: ~, I! Y4 R0 z$ H听诊心率次/分心律（齐不齐） 4 q6 ^! b) 1 绝对不齐心音 S1 正常增强减弱* m8 H9 J6 o S2 Q( d. [# {: X分裂 S2 正常增强减弱分裂. e' |' z8 [, X. Z( P" f S3 N Y S4 N Y A2 P2S3 无有 S4 无有 A2 P2N ( 额外心音无奔马律（舒张期收缩前期重叠) : N Y ( )开瓣音其他杂音无有（图示并描述传导）N M1 d* y3 g4 {心包摩擦音无有: 周围血管无异常血管征大血管枪击音. U' M ^4 L( w, u’s & S; ~8 S$ x 二重杂音水冲脉毛细血管搏动* l" P) n* h脉搏短绌奇脉交替脉其他腹部. z( X* L1 A3 }: ( ) 视诊外形正常膨隆蛙腹（腹围厘米）舟腹尖腹胃型肠型: 蠕动波腹式呼吸存在消失脐" [: q; Q8 p1 e) _6 I( e4 C: N Y( 正常凸出分泌物其他异常无有（腹壁静脉曲张)条纹手术疤痕疝）8 Z |5 @: J: N Y 触诊柔软腹肌紧张部位压痛无有 N Y N Y N Y5 Q! I, E3 I$ o5 N 反跳痛无有液波震颤无有振水音无有N Y( ) ’t 腹部包块无有（部位大小）特征描述肝未触及 # I6 r" r4 @7 V; W2 h 可触及肋下厘米剑突下 : ’t 特征描述胆囊未触及可触及1 O* X, j, a" YN Y ’s : ’t 大小厘米压痛无有征脾未触及可触及肋下厘米5 Q7 {" {& I" g: J1 p* {’t 9 e7 t6 Z5 Z7 \# Q6 F4 h 肾未触及可触及大小硬度: N Y ()压痛移动度输尿管压痛点无有（部位） }. ^5 F9 l) u: ( )叩诊肝浊音界（存在缩小消失）- B$ {. V$ X t 肝上界位于右锁骨中线肋间( r9 W5 z' X" C1 f' `; hN Y N Y ( )6 f7 K1 Y 移动性浊音无有肾区叩痛无有（右左） ~7 h3 h3 u) Y Q2 D: y( Y t5 l" r, r,Z1 I 听诊肠鸣音正常增强减弱; g( {4 R9 @5 |! TN Y N Y ()消失气过水声无有血管杂音无有（部位）6 E9d R7 F' A$ E R. S; H! ~7 k" u3 p 生殖器未查正常异常肛门直肠9 P; g$ m6 f) n0 p未查正常异常脊柱四肢: ( )4 g6 X. w1 p" q' T3 {脊柱正常畸形（侧前后凸）! p9 w9 x" \( e5 S: ( ) 棘突压痛叩痛（部位）) U, ]! O5 m) z: P : : * I, q( G$ q) d5 D移动度正常受限四肢正常异常畸形关节红肿关节强直肌肉压痛肌肉萎缩( ) ; P8 }7 h9 {& r' ?1 x下肢静脉曲张（部位及特征）杵状指神经系统( ) ( )腹壁反射（正常）肌张力（正常）( ) N Y ( / X5 g5 |5 g9 S8 P; a肌力（级）肢体瘫痪无有（左右) () () J7 }* P5 J; \7 ^上下）肱二头肌反射左（正常）右（正常） () ( ) 膝健反射左（正常）右（正常）跟腱反射左1 w6 \+ E4 A1 g() ( ) : F3 m! n7 w! C7 e6 L正常右（正常）’s (+)(-) (+)(-)征左（+）(-) 右（+）（-）’s (+)（-） (+)(-) # z: k5 x' P! P" Q3 L左（+）（-）右（+）（-）) h0 o, x' n" H5 G’s (+)（-）(+)(-) 7 S0 O) T3 ]+ A3 j征左（+）（-）右（+）（-）其他实验室及器械检查结果（ . ） (重要的化验、X线、心电图及其他有关化验)X线片号病历摘要()" W7 _" F6 b3 ]入院诊断。

英文大病历

Complete Medical HistoryName: Zhanghou Sex: maleProfession :peasant Age:31 yearsNative place: Tian Jin Address:chitu village chitu town dongli district tianjinMarital state: married Nationality: HanDate of admission: February 28 2003 Date of history taking :February 28 2003 Narrator: the patient Reliability of the history: reliableThe HistoryChief Complaint: lumbago for 2 years with weakness ,numbness in lower limbs, more severe 2 months.Present Illness:2 years ago ,after working ,the patient always felt lumbago, sometimes referred pain at the hip and lower extremities,mainly at the dorsal side.and the left lower limb was more severe. At the same time he felt weak and numb at lower limbs, also more severe in the left side. No muscle atrophy, no abnormal of stool and urine. No temperature abnormal or color changes in the local skin. No nails damaged. Then the patient went to the hospital in his town, and had a X-ray examination, shown hypertrophy in the lumbar vertebrae., given some drugs for pain-control. After having some drugs and more rest, the symptoms lightened. But 2 months ago ,without significant causes,the symptoms became more severe. The lumbago often made him sleepless at nights. And he can only walk 500 meters without a break. his left lower limb felt numb and weak.Having the drugs and rest both can not ease the symptoms. So he came to our hospital for advanced diagnosis and treatment. Since the disease, no changes in consciousness,body temperature, appetite, body weight .and normal of stool and urine.Past history: the patient had a history of high intensive working for about 10 years. No history of chronic diseases like hypertension, CAD and mellitus diabetics. No history of hepatitis or AIDS , tuberculosis .No history of trauma and operation. No history of hypersensitivity of any drug or food.Review of Systems:Respiratory system: no history of chronic cough , expectoration, hemoptysis , chest pain , or short of breath.Circulation system: no history of dyspnea or edema at the lower limbs. No history of palpitation or chest pain. No dizziness, headache, No history of hypertension.Digestive system: no history of anorexia, abdominal distention, regurgitation. No nausea and vomiting. No history of constipation , diarrhea ,melena and so on.Urogenital system: no history of swollen eyelids or lumbago. No frequent micturition, urgency of micturition or urodynia. No dysuria ,hematuria or retention and incontinence of urine .no history of acute or chronic nephritis.Hemopoeltic system: No pallid countenance ,weakness,dizziness , daze ,tinnitus. No history of bleeding and repeated infections. No history of enlargement of liver and spleen.Metabolic and Endocrine system:no abnormal cold or hot feeling, hidosis ,headache weakness,impaired vision,polyphagia ,polyuria ect.normal distributed hair.no change of temperand intelligence.Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal sensation or motion. No change of personality .no mania ,depression or hallucination. Motor system: lumbago and limitation of movement for 2 years. weakness and numbness at lower limbs, the left more severe. No spasm, atrophy or palalysis. No joint red swollen, hot ,pain or limitation of motion. No trauma or fracture.Personal history: born in her native place and living in Tianjin. No history of exposure to poison.No habits of drinking or smoking.Marital History:. Married at 24 years old and having a child. the child and his wife both health.Family history: denying the family history of any heredity diseases ,or MD, CAD, hypertension ect.Physical ExaminationTemperature: 36.5°C pulse rate: 72/min respiratory rate: 18/min blood pressure:130/80mmHgGeneral appearance : normal development and medium in nourished ,no abnormal consciousness, good corporation in examination. Free position.Skin and mucous membrane : No pallid , cyanosis, and jaundice . no abnormal pigmentation and depigmentation . no erythma annulare, petechia and spider angioma. Normal elasticity of skin, no edema.Superficial lymph nodes: no enlargement of the superficial lymph nodes.Head and its organs:Skull: no deformity, tenderness or mass. Evenly distributed hair with black color and shine. Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids. No pallor, granules ,follicles pectechiae of conjunctivae . transparent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization. No exophthalmos or enophthalmos.free motions of the eye balls in any direction. Equal and round pupils at both sides with diameter 4mm, normal and active direct and indirect light reflexs,normal accommodation and convergence reflexes. Vision , visual field and eyegroud not examined.Ears:no deformity .no abnormal secretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.Nose: no deformity. No deviation of septum nasi. No ala flutter. No edema ,abnormal secretion ,and congestion of the membrane . good ventilation. No tenderness in any paranasal sinuses.Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth, no caries. No bleeding or congestion ,lead line in gums. Thin and slight yellow fur coated on the tongue ,with normal in motion. No redness and congestion in pharynx ,no deviation of uvulae. No edema in tonsils. Neck: symmetry . no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins. No rigidity .no enlargement of thyroid glands ,and the trachea in the centeral position. No murmur. Negative of hepatojugular reflux.Chest: symmetry. No deformity. No barrel chest ,pigeon chest or funnel chest. No tenderness over the chest .the thoracic respiration present. R 18/min, symmetry in both sides. Symmetry and noabnormality of the 2 breasts.Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration. Respiratory movement equal in both sides and regular . no dyspnea or three concave sign.Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus. No pleural friction fremitus . no subcutaneous crepitation.Percussion: resonance in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th ,8th ,10th on midclavicular ,midaxillary,midcapular line respectively. The movement of the lower margin of the lungs: 6 cm..Auscultation: clear of vesicular breathing sounds all over the lung fields. No moist rales or rhonchis .normal of vocal resonance. No pleural friction sound.Heart:Inspection: no precordial bulging. Apical impulse in the 5th ICS 1cm inside of left midclavicular line with an area of 2 cm in diameter.Palpation: apical impulse and its area as that in inspection. Regular ,normal intensity. No pericardial friction rubs or thrill.The distance between the left midclvicular line and the midsternal line is 8cm.Auscultation: HR 72/min with regular rhythm, heart sounds clear and intensive . no murmurs at any auscultation area of the valvula. No pericardical friction sound.Radial arteries: pulse rate 85/min, with regular rhythm, equal in both sides, normal intensity . Perivascular signs: no capillary pulsation, water hammer pulse ,pistol-shot sounds and Duroziez’s murmur . no pulse deficit, and pulse alternant.Abdomen:Inspection: symmetry. No bulge abdomen ,abdominal distention .normal abdominal respiration. No visible gastrointestinal waves. No varicosity , scar ,petechia at the abdominalSkin.Palpation: soft, no tenderness and rebounding tenderness, no tightened abdominal wall. No palpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphy’s sign.Kidneys: not palpable. No tenderness in the any site of kidneys or ureters.Spleen: not palpable.Appendix: no tenderness at the Mcburney’s site.Percussion: tympany in all over the abdomen, no shifting dullness. No percussive pain of liver and spleen. The upper margin of liver at the 5th ICS in the right midcalvicular line Auscultation: normal borhorygmus, 4/min, no murmur of vessels. No friction rubs .Anus and rectum: not examined.Spine: no lordosis, kyphosis, or scoliosis. tenderness and punching tenderness at the level ofL3-L5. Limitation of movement, especially anteflextion. No changes in the local skin. Extremities: symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.myodynamia of left lower limb in 4th grade and right lower limb in 5-th grade. Details in the special condition.Nerve system:numbness in lower limbs ,more severe in left side. Normal sensation.at other place. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle clonus.Laboratory findings:Blood routine: WBC 7.3*10ª ,N 0.65, L 0.35,Hb 141g/l .RBC 4.38*1012/l ,plt 238*10ª/l. X-ray: hypertrophy of lumbar vertebrae.MRI : the results not gotten.Special condition:no lordosis, kyphosis, or scoliosis of spine. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skins. extrmities symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.Muscular tension of left lower limb in 4th grade and right lower limb in 5-th grade. Sensation in left lower limb decreased. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle segue sign(+).SummaryThe patient named Zhanghou ,male ,is 31 years old,admission with the chief complaint of lumbago for 2 years with weakness and numbness in the lower limbs, more svere for 2 months.2 years ago ,after working ,the patient always felt lumbago, sometimes referred pain at the hip and lower extremities,mainly at the dorsal side.and the left lower limb was more severe. At the same time he felt weak and numb at lower limbs, also more severe in the left side. No muscle atrophy, no abnormal of stool and urine. No temperature abnormal or color changes in the local skin. No nails damaged. Then the patient went to the hospital in his town, and had a X-ray examination, shown hypertrophy in the lumbar vertebrae., given some drugs for pain-control. After having some drugs and more rest, the symptoms lightened. But 2 months ago ,without significant causes,the symptoms became more severe. The lumbago often made him sleepless at nights. And he can only walk 500 meters without a break. his left lower limb felt numb and weak.Having the drugs and rest both can not ease the symptoms. So he came to our hospital for advanced diagnosis and treatment. Since the disease, no changes in consciousness,body temperature, appetite, body weight .and normal of stool and urine.PE: T:36.5°C, Bp 130/80mmHg,normal development, moderately nourished, clear counsciousness. Good corporation in physical examination. Normal in skull ,neck,lungs ,heart and abdomen no lordosis, kyphosis, or scoliosis of spine. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skins. extrmities symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.Muscular tension of left lower limb in 4th grade and right lower limb in 5-th grade. Sensation in left lower limb decreased. Biceps,triceps ,radioperiosteal , andabdominal wall reflexes normal.while knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle segue sign(+). Blood routine: WBC 7.3*10ª ,N 0.65, L 0.35,Hb 14.1g/l .RBC 4.38*1012/l ,plt 238*10ª/l.X-ray: hypertrophy of lumbar vertebrae.MRI : the results not gotten.Impression:Intern doctor :Bianbo。

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住院病历（一）(Medical Records for Admission)入院记录(General Information for Hospital Record)姓名(Name)：邮编(Post Code)：性别(Sex)：MALE单位或现住址（Address)：年龄(Age)：56years old身份证号码(Identification No.)：婚姻(Marital Status)：Married户口地址(Registered Residence Address)：民族(Race)：汉族联系电话(Contact Number):出生地(Place of Birth):FUDING入院日期(Date of Admission)：2013-08-0513:04:22职业(Occupation):病史陈述者(Complainer of History):主诉(Chief Complaint)：headache and fever for10days.现病史(History of the Present Illness)：10days ago,the patient had headache for no obvious reasons.There was persistent pain on the external parietal part of the head.The pain was not related to postural changes.The trigger was unclear but was accompanied by住院病历（二）(Medical Records for Admission)既往史(Past Medical history)：General health status:normalCo-morbid conditions:Hypertension:Absent Cardiac disease:AbsentDiabetes mellitus:Absent Kidney disease:AbsentHistory of infectious diseases:Tuberculosis:Absent Hepatitis:AbsentOthers:29years ago,he had a renal history of tuberculosis.History of preventive inoculation:Inoculation plan completed.Allergic History:History of blood transfusion:Negative1.Drug:Negative History of scars/wounds:Negative2.Food:Negative History of surgical operations:Negative3.Others:NegativeHistory of long-term drug use:NegativeHistory of drug abuse:Negative系统回顾(Review of Systems)：•HEENT:No hearing loss,tinnitus,dizziness,tooth ache,gingival bleeding, throat ache,hoarseness.•Respiratory:no chronic cough,sputum,expectorant,chest pain,asthma, dyspnea.•Cardiovascular:No increase in blood pressure,palpitation,shortness of breath,cyanosis,precardial pain,orthopnea,dizziness,lower limb edema.•GI:No hematemesis,swallowing difficulty,abdominal pain or distention, diarrhea,occult blood,constipation,jaundice,rash or itching.•Genitourinary system:No urinary frequency,urgency,dysuria,hematuria, pyuria,nocturia or frothy urine.•Hemapoietic:No ecchymose,purpura,lymphadenopathy,splenomegaly, epistaxis or gingival bleeding•Endocrine:no polydipsia,polyphagia,polyuria,change in sexual function or personality or visual field defect.•Musculoskeletal:No dysarthria,joint abnormality,spine abnormality,muscle atrophy or weakness in limbs.•Neurology:no headache,loss of memory,aphasia,paralysis,tic.•Mental state:no hallucination,delusional,disorientation,mood disorder个人史(Personal history)：Place of birth:Residence:Epidemic area:None Travel history:Negative Drinking history:Yes500ml/day for30years and stopped2years agoSmoking history:Yes20cigarettes/day for30years and stopped for2months Toxin,dust,radioactive or industrial exposure:Negative婚姻、月经及生育史(Marital、Menstrual and Childbearing history):Marital status:Married Age of wedding:25years old spouse heath:normal children:2sons and1daughter;all healthy家族史(Family History)：Father- deceased Condition:unknownmother- deceased Condition:unknownSiblings:HealthyHereditary disease(s):NegativeCongenital disease(s):Negative in grandparents,parents or siblings.住院病历（三）(Medical Records for Admission)体格检查(Physical Examination)一般情况(General Appearance)Consciousness:Refer to speciality Pulse rate:78bpm Respiratory rate:20 times/min Blood pressure:128/70mmHg Temperature:38.8°CWeight:not measured kg Height:not measured cm Posture:Can answer correctly and collaborates.皮肤、黏膜(Skin、Mucosa)：Color:Refer to speciality Rash:Absent Hemorrhage:Absent Edema:refer to specialitySuperficial lymph nodes:No enlargement of superficial lymph nodes in the whole body头部及其器官(Head and HEENT)：Shape of head:Normal Conjunctiva:No hyperemia or edema Sclera:Refer to speciality Pupil:Symmetrically round Nasal cavity:Clear Sinus tenderness:Absent Teeth:Normal Oral mucosa:Normal Mastoid tenderness:Absent Hearing:No abnormality Tonsils:No enlargement Others:Negative颈部（Neck）:Flex:Soft position of trachea:Midline thyroid gland:No enlargement Jugular vein:No distension Others:None胸部(Chest)：Shape:Normal,symmetric intercostals space:Normal Breasts: Symmetric,no abnormality肺脏(Lungs)：Breathing:Symmetric percussion sound:Clear breath sounds:Clear Crackles:Absent Others:Absent心脏(Heart)：Heart rate:78bpm Heart sounds:Normal Murmurs:Absent Others:Absent血管(Blood Vessel)：Peripheral vessel sign:Negative腹部(Abdomen)：Refer to speciality外生殖器(Genitourinary system)：not examined直肠、肛门(Rectum、Anus)：Not examined四肢、脊柱(Extremities、Spine)：No abnormality神经系统(Neural System)：Muscle strength:Grade5Muscle tension:NormalKnee-jerk reflex:Normal Babinski’s sign;left:negative,right:negativeOthers:kernig(+)其他体征(Other Physical Signs)：Normal住院病历（四）(Medical Records for Admission)专科情况(Specific Appearance)：General condition:Dulled consciousness,NO left supraclavicular lymph node enlargement,no icterus,no lower limb edema,no palmar erythema,no spider telangiectasia,no skin pigmentation,no flapping tremor,no capillary distension,no fetor hepaticus.Abdomen:1.Inspection:External appearance:Smooth Abdominal vein distension:Absent Breathing type:hyperventilated Breathing movement:NormalSurgical scar:Absent Discoloration:Absent2.Palpation:No pain Pain with pressure or rebound tenderness:Absent Swelling:Absent Liver:Palpable Gall bladder:Absent,no pain with pressure,negative Murphy sign Spleen:Not palpable Kidney:Not palpable Bladder:Full(distended)3.Percussion:Dullness of border of liver:On right,mid-clavicular line on the5th ICS(Upper border)of a length of about9cm,no percussion pain on the region of the liver or gall bladder Dullness of border of spleen:Left mid-axillary line9-11th ICS,about9cm No shifting dullness,no percussion pain of the costophrenic region.4.Auscultation:Borborygmus:Normal No metallic sound5.Others:None特殊检查(Special Examination)：MRI:Intracranial CT scan shows no change,renal atrophy with multiple stones mainly in bladder, left ureter.There is gall bladder bile duct stone.There is pneumonia with bilateral pleural effusion.Bilateral centrum ovale multiple lacunar white matter changes in atherosclerotic lesions of chronic sinusitisLabs Data:2013/07/28Csf culture:protein+,wbc356*10^6/L,Monocyte85%,cl119mmol/l,Glucose 1.74mmol/L,protein1.79g/lCSF culture2013/07/31CSF:RBC18*10^6/L,WBC220*10^6/L,Monocyte:90%,CSF biochemistry:CL115mmol/L,Glucose1.91mmol/L,Protein1.68g/L,ADA:6U/L初步诊断(Primary Diagnosis):Intracranial infectionTuberculous meningitis。