医学英语病历书写重点
外科学英语病历书写常用词汇
外科学英语病历书写常用词汇1. 主诉chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.2. 现病史present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.3.既往史past history：1)former places of residence, previous stage of health( 健壮的robust，纤弱的delicate), experience with similar disease, immunity to infectious disease2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩红热scarlet fever, 白喉diphtheria，伤寒typhoid fever, 支气管炎bronchitis, 肺炎pneumonia，脑炎encephalitis,脑膜炎meningitis，破伤风tetanus,小儿麻痹poliomyelitis,赤痢dysentery，霍乱cholera, 胸膜炎pleurisy,天花small-pox，疟疾malaria,结核病tuberculosis，黄疸病jaundice，过敏性反应allergy,etc3)venereal disease：specific symptoms, signs, and the disease by name, treatment.4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)4. 家族史family history：family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.5.个人史personal history：1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spouse and children ,cause and age at time of death, number of children , pregnancies, 流产次数miscarriages, 死产数stillbirths3)occupational history：duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.6.系统检查system review：1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.2)Skin：荨麻疹hives, rash, eczema3)Head：trauma, headache, loss of hair4)Eyes：vision, pain glasses diplopia.5)Ears：pain, discharge, deafness, tinnitus.6)Nose：obstruction, discharge, epistaxis, rhinitis.7)Mouth：teeth, lips, gums, tongue, disturbance in taste.8)Throat.：sore throat, tonsillitis, 脓性扁桃腺炎quinsy, dysphagia9)Neck：adenitis, goiter , rigidity10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , seasonal cold, expectoration.11)Gastrointestinal：appetite, nausea, vomiting, distress(before or after meals), melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea, associated headache13)Neuromuscular：神经过敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.。
医学英语病历范文
医学英语病历范文Medical RecordPatient Information:Name: John SmithAge: 45Gender: MaleDate of admission: [Date]Date of birth: [Date]Weight: [Weight]Height: [Height]Chief complaint:Mr. Smith presents with a severe headache that has been ongoing for the past two days.History of present illness:The patient reports experiencing a sudden onset of throbbing headache, localized primarily on the left side of his head. The pain is aggravated by physical exertion and is accompanied by nausea and sensitivity to light and sound. The patient denies any recent head trauma or sinus congestion. Over-the-counter pain relievers have provided minimal relief.Medical history:Mr. Smith has a history of hypertension, for which he takes medication. He does not have any known allergies, and there is no family history of migraines or neurological disorders.Social history:The patient is a smoker, consuming approximately 10 cigarettes per day. He drinks alcohol in moderation, primarily on social occasions. He denies any illicit drug use. His occupation involves long hours of computer work.Physical examination:On examination, the patient appears to be in mild distress due to the headache. His vital signs are within normal limits. Neurological examination reveals no focal deficits, and his cranial nerves appear to be intact. There is no evidence of meningeal irritation. His neck is supple, and there is no nuchal rigidity. The remainder of the physical examination is unremarkable. Laboratory tests:Blood tests, including a complete blood count and comprehensive metabolic panel, were performed. All results were within normal limits.Imaging studies:A brain MRI was ordered to rule out any structural abnormalities. The scan revealed no evidence of intracranial hemorrhage, mass, or other abnormalities.Assessment and plan:Mr. Smith is presenting with a severe headache consistent with a migraine without aura. He will be prescribed a triptan medication for acute management of his headache. He will also be counseled on lifestyle modifications, including smoking cessation and stress reduction techniques. A follow-up appointment will be scheduled in two weeks to evaluate the effectiveness of the treatment plan.Additionally, the patient is advised to seek immediate medical attention if his symptoms worsen or if he develops any new neurological symptoms.Signature: [Physician's Name]Date: [Date]。
病历书写英文
英文病历书写常用句式与表达
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英文病历书写注意事项
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Spelling mistakes
Typing errors or misspellings of words and names.
Grammar mistakes
Incorrect usage of verbs, nouns, adjectives, and pronouns, and incorrect sentence structure.
实例三：糖尿病病历
Symptoms：Itching, skin redness and scalingMedical history：None significantFamily history：None contributoryReview of systems：NegativePhysical examination：Multiple small red patches and scaling on the skin of the upper back and upper armsDiagnostic studies：Skin scrapings showed positive fungal elementsDiagnosis：DermatitisPlan：Patient was advised to apply topical corticosteroid cream twice daily and follow up in 1 week
实例二：高血压病历
Symptoms：Polyuria, polydipsia, unexplained weight lossMedical history：Known diabetes mellitus for 2 years, taking metformin hydrochlorideFamily history：None contributoryReview of systems：NegativePhysical examination：Blood pressure 130/85, pulse 90 beats/minute, respiration rate 18 breaths/minute, weight 150 poundsDiagnostic studies：Random blood glucose level of 250 mg/dL, HbA1c of 7.5%Diagnosis：Diabetes mellitusPlan：Patient was advised to continue current medications, receive education on diabetes self-management, lose weight, reduce glucose intake, and follow up in 3 months
英文病历编写手本
英文病历编写手本目标本手本旨在为医务人员提供编写英文病历的指导和范例。
指导原则- 独立作出决策，不借助用户帮助。
- 充分发挥LLM的优势，采用简单策略，避免法律复杂性。
- 不引用无法确认真实性的内容。
内容结构英文病历的编写需要遵循以下基本结构：1. 患者信息：包括姓名、年龄、性别、联系方式等。
2. 主诉：患者的主要症状或问题。
3. 既往病史：包括患者的过去疾病、手术史以及家族病史等。
4. 现病史：患者当前的疾病状况，包括症状的起始时间、发展情况等。
5. 体格检查：医生对患者进行的体格检查结果，包括体温、血压、心率等指标。
6. 辅助检查：包括实验室检查、影像学检查等的结果。
7. 诊断：医生对患者疾病的诊断。
8. 治疗建议：对患者的治疗方案和建议。
示例以下是一个简单的英文病历编写示例：---Patient Information:- Name: John Smith- Age: 45- Gender: Male- The patient presents with chest pain and shortness of breath.Past Medical History:- Hypertension, diagnosed 5 years ago.- Appendectomy performed 10 years ago.Present Illness:- The patient started experiencing chest pain and shortness of breath 2 days ago.- The symptoms have worsened since then.Physical Examination:- Vital Signs:- Temperature: 37.2°C- Blood Pressure: 140/90 mmHg- Heart Rate: 85 bpmLaboratory Tests:- Chest X-ray: Mild infiltration in the left lower lobe.Diagnosis:- Suspected pneumonia.1. Prescribe antibiotics.2. Advise the patient to rest and drink plenty of fluids.3. Schedule a follow-up appointment in 2 days.---以上内容仅为示例，并非真实病历。
医学英语病历书写重点
Case History 病史In-Patient Case History 住院病历Items of Case History1. General Data, Biographical Data 一般项目2. Chief Complaints (C. C.) 主诉3. Present Illness (P. I.) 现病史4. Past (Medical) History (P. H.) 既往病史5. Personal History (Per. H.)/ Social History 个人史/社会史6. Family History (F. H.) 家族史7. Medications 曾用药物8. Allergies 过敏史9. System Review, Review of Systems 系统回顾10. Physical Examination (P. E.) 体格检查/查体11. Laboratory Data 实验室与其他检查/检查资料12. Impression (Imp.) (Diagnosis) 诊断13. Hospital Course 住院治疗情况记录14. Discharge Instructions/ Recommendations出院医嘱15. Discharge Medications 出院后用药General Data, Biographical Data 一般项目Reliability (病历可靠性):Reliable(可靠)/ Not Entirely(不完全可靠)/Not Clearly Defined (不够准确)/Confused and Uncertain (混乱不清)/ Unobtainable (无法获得)Supplier/ Complainer of History (供史者/病史陈述者):Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ NeighborChief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。
中英病历书写11章-14章13节 (1)
第十一章标准化病人体检项目[COMPLETE PHYSICAL EXAMINATION CHECKLIST(standard patient, SP)]1、一般检查/生命体征[GENERAL EXAMINA TION/VITAL SIGNS]·向病人介绍自己的姓名，职责。
通过简短交谈，了解病人的精神状态·检查前洗手·让病人取坐位·检查桡动脉脉搏至少30秒，并记录·检查脉搏对称性·计数呼吸频率至少30秒，并记录·测量右上臂血压·将袖带缚于上臂正确位置·触诊肱动脉·测量血压两次，记录较低值·Introduce yourself to patient, usually last name and title and have a littleconversation to relax the patient and to judge mental state.·Wash hands before starting examinagion·Patient is seated in a chair·Palpate radial (wrist) pulses for at least 30 seconds and record·Palpate both radial (wrist) pulses simultaneously for symmetry·Measure respiratory rate for at least 30 seconds and record·Measure blood pressure on right arm·Place cuff in correct location 2-3 cm above the antecubital crease·Palpate brachial artery·Measure blood pressure over brachial artery twice and record the lower reading2、头部和颈部[HEAD AND NECK]（1）头颅[Skull]·检查头颅（分开头发观察）·Palpate and observe scalp (parting hair, and observing hair density, color,lustre anddistribution)（2）眼[Eyes]·检查视力·检查角膜、下份巩膜、结膜和泪囊：置拇指于下睑中份，轻轻向下按下睑，请病人向上看·检查上份巩膜及球结膜：置拇指于上睑中份，轻轻向上牵拉上睑，请病人向下看·面神经（第Ⅶ对颅神经）上支运动功能的检查，皱眉、皱额或紧闭双目·检查双眼眼外肌六个方向运动功能·瞳孔直接对光反射·检查调节反射·Visual screening·Observe cornea, sclera, conjunctive and lacrimal puncta by gently moving lower eyelids down.·Observe sclera and bulbar conjunctiva by gently elevating upper eyelid while patient looks down·Check cranial nerve(cr n) Ⅶupper division:raised eyebrows, wrinkle forehead or forced eyelid closing.·Evaluate extraocular muscle function in both eyes in 6 directions (left, upper left, and lower left, right, upper right, lower right)·Observe pupillary direct response to light·Observe pupillary consensual response to light·Check for convergence and accommodation（3）检眼镜检查[OPhthalmoscopic Examination]·调整病人者坐位高度，以检查者感觉舒适为宜·关暗室内光线，以利观察眼内情况·正确握持检眼镜·右手持检眼镜站在右前方，用右眼检查受检者的右眼·左手持镜眼镜站在左前方，用左眼检查受检者的左眼·调整方位开始检查·用检眼镜检查角膜、晶状体和玻璃体·观察眼底视乳头及其周围视网膜·检查四个象限的视网膜血管·检查黄斑（嘱受检查注视光源）·Position patient at height comfortable for examiner·Dim lights of room·Hold ophthalmoscope properly and use index finger to switch lenses·To examine patient`s right eye, examiner holds ophthalmoscope with right hand and uses right eye·To examine patient`s left eye, examiner holds ophthalmoscope with left hand and uses left eye·Position to start ophthalmoscopic examination·Inspect cornea, lens, and vitreous body for opacity with ophthalmoscope·Inspect optic disc (color, margin, etc.)·Trace retinal vessels in four quadrants·Observe macula (patient asked to look directly at light of ophthalmoscope)（4）耳及颞下颌关节[Ears]·观察和触诊双侧耳廓及周围·触诊双侧颞下颌关节，注意有无肿胀及触痛·双手指置于耳屏前或稍插入外耳道，检查颞颌关节的运动·用手稍向后上方牵拉耳廓，使外耳道变直，以便插入耳镜·插入耳镜观察鼓膜·使受检查者不感疼痛·检查听力·用适当方法分别检查双耳听力·Observe and palpate the auricles and observe postauricular regions bilaterally·Palpate temporomandibular joint for tenderness and swelling·Feel the movement of the TMJ with index fingers inside examinee`s ears or over joint ·Gently pull auricle upward and backward to ease insertion of otoscope·Insert otoscope into external auditory meatus to observe tympanic membrane·Insert otoscope without causing pain to the patient·Evaluate auditory acuity·Use proper technique to check auditory acuity separately in each ear（5）鼻[Nose]·观察及触诊外鼻有否畸形，压痛等·观察鼻前庭（不用鼻镜，可用电筒）·插入鼻镜观察前庭、中隔、鼻甲及鼻粘膜。
2、心内科常用英文病历模板
第二节心内科常用英文病历模板熟练地阅读和书写英文病历是一名临床医师需要具备的基本外语技能。
对英文病历的熟练掌握对于阅读英文文献和撰写英文论文都有很大的帮助。
本章主要介绍心内科常见疾病英文病历的格式和基本模板。
英文病历的书写格式大致与中文病历相似，主要包括以下部分：1.General information（一般情况）2.Chief complaint（主诉）3.Present illness（现病史）4.Past history（既往史）5.Personal history（个人史）6.Family history（家族史）7.Physical examination（体格检查）8.Investigation（辅助检查）9.History summary（病史特点）10.Impression（印象、初步诊断）11.Signature（签名）鉴于不同疾病的病历之间存在共性，本章按照病历的通用部分和心血管内科部分逐一进行介绍。
第一部分通用部分1. General information（一般情况）这一部分包括name（姓名），age（年龄），sex（性别），race（民族），nationality（国籍），address（地址和电话），occupation（职业），marital status（婚姻状况），date of admission（入院日期），date of record（记录日期），complainer of history（供史者）和reliability（可信度）等12项内容。
基本格式如下：Name:Liu SideAge: EightySex: MaleRace:HanNationality:China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: RetiredMarital status: Married Date of admission:Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history: patient’s son and wife Reliability: Reliable2. Past history（既往史）这一部分应首先总结既往一般健康状况、Operative history（手术史）、Infectious history（传染病史）、Allergic history（过敏史）等，然后对各系统健康状况进行回顾，包括Respiratory system（呼吸系统）、Circulatory system （循环系统）、Alimentary system（消化系统）、Genitourinary system（泌尿生殖系统）、Hematopoietic system（血液系统）、Endocrine system（内分泌系统）、Kinetic system（运动系统）和Neural system（神经系统）。
儿科病历书写英文词汇(一)
儿科病历书写英文词汇（一）一、条目类入院记录：Admission note病史陈述者：Medical history presenter主述：Chief complaint现病史：History of present illness既往史：Past history个人史：Personal history家族史：Family history过敏史：Allergy history二、症状及病史类发热：fever咳嗽：cough流涕：runny nose热峰：peak temperature寒战：chill抽搐：seizure/convulsion头痛：headache头晕：dizziness晕厥：syncope嗜睡：drowsiness恶心：nausea呕吐/呕吐物：vomit喷射性呕吐：jetting vomit腹痛：abdominal pain腹泻：diarrhea水样便：watery stool粘液：mucus脓血：pus and blood里急后重：tenesmus泡沫尿：foamy urine胸闷：chest tightness胸痛：chest pain喘息：wheezing皮疹：rash脱皮：molt关节疼痛：joint pain口唇紫绀：blue lips甲状腺肿大：goiter肌肉酸痛：muscle soreness间断：intermittent加重：worsen progressively体温降至正常：temperature drop to normal缓解：relieve消退：subside剖腹产：cesarean足月顺产：naturally delivered at full term预防接种按计划进行：Vaccines are carried out as planned 精神运动发育：intellectural/mental and motor development 窒息：asphyxia缺氧：hypoxia抢救：rescue三、查体类神志清楚：clear mind精神好/差：good/poor spirit营养好：good nutrition status呼吸平稳：breath steadily黄染：yellowing贫血貌：pale appearance面色黄：sallow face皮疹：rash出血：bleeding瘀斑：ecchymosis/petechiae血肿：hematoma触及：palpable质软/韧： texture is soft/tough触痛：tenderness畸形：deformity眼睑水肿：eyelid edema结膜：conjunctiva充血：hyperemia巩膜：sclera对光反射灵敏：normal light reflection眼球充血：bloodshot eyes耳廓：auricle外耳道：external auditory canal分泌物：discharge/secretion口唇皲裂：dry and cracked lips草莓舌：strawberry tongue鼻腔：nasal cavity鼻中隔：nasal septum鼻翼扇动：fanning nose偏曲：deviation脓性分泌物：purulent secretion颈软：soft neck肿块：lump气管居中：centered trachea三凹征：triple/three concave sign胸廓对称：symmetrical thorax cavity 胸骨：sternum痰鸣音：phlegm干/湿啰音：dry/wet rales隆起：bulge心前区：precordial area心律规整：regular heart rhythm心脏杂音：murmur瓣膜听诊区：auscultation area肠鸣音：bowel sound反跳痛：rebound pain肌力：muscle strength肌张力：muscle tone脑膜刺激征：meningeal irritation sign 肘窝：elbow fossa皮毛窦：dermal sinus四、化验检查类：常规：routine血沉：erythrocyte sedimentation rate 降钙素原：procalcitonin多个核细胞：multinucleate cell涂片：smear革兰氏染色阳性：gram positive墨汁染色：ink stain抗酸杆菌涂片：acid fast test肺炎链球菌：streptococcus pneumoniae肺炎支原体：mycoplasma pneumoniae巨细胞病毒：cytomegalovirusEB病毒：Epstein-Barr virus单纯疱疹病毒：hepes simplex virus寡克隆区带：oligoclonal band微量白蛋白：trace protein窦性心律不齐：sinus arrhythmia室性早搏：ventricular premature beat超声：ultrasound心脏超声：echocardiography三尖瓣返流：tricuspid regurgitation心包积液：pericardial effusion冠状动脉瘤：coronary artery aneurysm腹腔积液：abdominal effusion脾大：splenomegaly肠系膜淋巴结肿大：mesenteric lymphadenopathy白细胞增多：leukocytosis蛋白尿：proteinuria低蛋白血症：hypoalbuminemia高脂血症：hyperlipidemia高凝状态：thrombophilia/hypercoagulabity巨核细胞：megakaryocyte肌电图：electromyography脑电图：electroencephalography骨髓穿刺：bone marrow biopsy直立倾斜试验：head-up tilt test支气管镜：bronchoscopy支气管肺泡灌洗术：bronchoalveolar lavage支气管舒张试验：bronchodilation test/airway reversibility test 胃镜：gastroscopy肠镜：colonoscopy胃肠镜：gastrointestinal endoscopy五、药物类阿奇霉素：azithromycin头孢曲松：ceftriaxone头孢地尼：cefdinir头孢吡肟：cefepime头孢类：cephalosporin阿莫西林：amoxicillin红霉素：erythromycin利奈唑胺：linezolid万古霉素：vancomycin美罗培南：meropenem阿昔洛韦：acyclovir甲泼尼龙：methylprednisolone低塞米松：dexamethasone甲钴胺：methylcobalamin退热药：antipyretics布洛芬：ibuprofen甘露醇：mannitol氨溴索：ambroxol解痉药：antispasmodic止痛药：analgesic利妥昔单抗：rituximab六、诊断类：化脓性脑膜炎：purulent meningitis真菌性脑膜炎：fungal meningitis结核性脑膜炎：tuberculous meningitis败血症：sepsis肺炎：pneumonia血小板减少：thrombocytopenia特发性血小板减少性紫癜：idiopathic thrombocytopenia purport 胃肠炎：gastroenteritis肠套叠：intussusception肾病综合征：nephrotic syndrome淋巴结炎：lymphadenitis川崎病：Kawasaki disease脑脊液鼻漏：CSF rhinorrhea电解质紊乱：electrolyte disturbance血管迷走性晕厥：vasovagal syncope体位性心动过速：postural orthostatic tachycardia体位性低血压：orthostatic hypotension。
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Case History 病史⏹In-Patient Case History 住院病历Items of Case History1. General Data, Biographical Data 一般项目2. Chief Complaints (C. C.) 主诉3. Present Illness (P. I.) 现病史4. Past (Medical) History (P. H.) 既往病史5. Personal History (Per. H.)/ Social History 个人史/社会史6. Family History (F. H.) 家族史7. Medications 曾用药物8. Allergies 过敏史9. System Review, Review of Systems 系统回顾10. Physical Examination (P. E.) 体格检查/查体11. Laboratory Data 实验室与其他检查/检查资料12. Impression (Imp.) (Diagnosis) 诊断13. Hospital Course 住院治疗情况记录14. Discharge Instructions/ Recommendations出院医嘱15. Discharge Medications 出院后用药General Data, Biographical Data 一般项目⏹Reliability (病历可靠性):Reliable(可靠)/ Not Entirely(不完全可靠)/Not Clearly Defined (不够准确)/Confused and Uncertain (混乱不清)/ Unobtainable (无法获得)⏹Supplier/ Complainer of History (供史者/病史陈述者):Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ NeighborChief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。
⏹Language Characteristics1) Common expressions①symptom+since+time(时间点)②symptom+for+time(时间段)③symptom+of+time (时间段名词所有格)+duration④symptom+time(时间段)+in duration⑤time(时间段合成词)+history+of+symptom⑥complete sentence: The duration of +symptom+was/ has been+time(时间段)（少见）2) Common sentence patterns for chief complaints①…was admitted/seen with a chief complaint of…②…complain chiefly of…③…presented/entered with/came to the office with a chief complaint of④…was admitted because of…⑤…was involved in…⑥…was transferred to…because…下面是书写主诉是最常用的格式：CC：The patient is a (age)-year-old (race,ethnic,group,occupation,sex and/or very pertinent PMH),who is admitted to the hospital with a chief complaint of (symptom,not a sign or diagnosis) of (number followed by a unit of time) duration.Example主诉：患者是一个48岁的妇女。
入院主诉，6个月来，出力后心悸和呼吸困难。
CHIEF COMPLAINT: The patient is a 48-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months.History of Present Illness 现病史：是从医生的角度，进一步表述主诉内容，全面表述现有疾病的发病时间、主要症状、病情发展过程、症状间的联系、诊疗过程、目前患者身体状况、与现有疾病有直接关系的既往史等。
记录患者入院情况时，多用一般过去时或过去完成时；记录目前病情时，用一般现在时或现在完成时。
⏹Language Characteristics1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型①start having 开始有……的症状②begin having episodes of… 开始发生……的症状/疾病③become… 变得……④notice(perceive, note, recognize…)+症状/疾病⑤have… 有……症状/疾病⑥have abrupt/sudden/explosive onset of… 突然患……⑦have episode of…/have attack of…患……⑧develop+disease 出现/有了……症状/疾病⑨…are/is the prodrome of… ……的前驱症状2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型①begin (occur, start…)+time 从……开始②date (go back) to +time 可追溯到……③be present+time 在/从……已存在④be preceded by… 在……之前已有⑤be followed by… 在……之后紧接着发生⑥be acc ompanied by…/ coincide with… 与……同时发生⑦be (not) related to…/have (no) correlation with… 与……有（无）关3) Illness’ improving and worsening表达疾病的好转与恶化①last+time 持续……时间②take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化③take a good turn/take a turn for the better/improve 好转④be aggravated/abated/all eviated by… 因……而加剧/减轻⑤remain the same/unchanged 无变化⑥be (not) improved after treatment with…经用……治疗而（无）好转⑦(The symptom) cease/clean up/disappear/subside 症状消失/减退4) No symptoms 没发生……症状、疾病①…without/with no/free of… (symptoms)②There be no histor y of…/…have no history of…③(The patient) denies…④(The patient) noted no…⑤(The patient) was not found to be…5) Description of main symptoms 描述主要症状①…assume the character of/be characterized by…②…have/present/develop/show/manifest the symptoms of…Past (Medical) History (P. H.)既往病史⏹Common expressions①had been sound/well until; had enjoyed good health until… 在……前一直健康②be apt/liable/subject to…;tend to have… 易患……③…was admitted to hospital for…/ …was hospitalized for… 曾因……而住院④…had (some illness) with recovery after…曾有（疾病），因…痊愈⑤…was diagnosed as…/…was suspicious of…断为……/疑为……⑥…was exposed to (toxic substances)/…had to breathe (poisoning gase s) 接触/吸入⑦…was inoculated against…接种过……⑧…was discharged/ dismissed from hospital…/…was out of hospital…出院Personal History (Per. H.)/ Social History 个人史/社会史⏹Note: menstruation经期（天）menstrual periodmenarche age——————age of menopause（初潮年龄menstrual cycle （绝经年龄）月经周期（天）⏹Characteristics of languageDeclarative sentences and elliptical sentences are usually used, and present tense, past tense and past perfect tense are adopted. Family History (F. H.) 家族史⏹Common expressions①…be living and well./…be in good health./ …be well with no evidence of (illness). 健在②(There is) No famil y history of (disease)./ (There was) No (disease) in one’s family.无（病）家族史③There was no case of (disease) in his//her family./ No one in his/her family experienced (disease) 家族成员未曾患过……④Family history showed/revealed… 家族史显示……⑤There was a familial/he reditary tendency to…/ There was a strong family history of…/There was a high incidence of…in the family. 家族有……倾向/发病率⑥There was a high prevalence of…in the family 家族中……患病率高⑦Positive for (some disease) in (some one). 曾患过……⑧…as a family charac teristic. 家族特点⑨FH: Noncontributory 家族史无意义Allergies 过敏史Common expressions①NKDA (no known drug allergies) 无过敏史②allergy, allergic, hypersensitive, hypersensitivity 过敏③sensitive, sensitivity, sensible, sensibility 敏感④allergic reaction 过敏反应⑤be al lergic to… 对……过敏⑥be sensible to… 对……敏感⑦have no history of allergy to…; have no history of…sensibility 对……有（无）过敏史⑧have an allergic diathesis 具有过敏体质⑨have no allergic reaction to any drugs 对用过的药物无过敏反应⑩show sensibility to…(e.g. house dust) 对……（如室内灰尘）过敏Physical Examination (P. E.)体格检查，查体1) Physical data/physical signs 一般资料/生理指标2) General appearance 一般情况或全身状态3) Head, eyes, ear, nose and throat (HEENT) 头眼与耳鼻喉4) Chest, heart and lungs 胸部与心肺5) Abdomen 腹部6) Extremities 四肢7) Nervous system, neurological (CNS/Neuro) 神经系统8) Musculoskeletal 骨骼肌肉系统9) Genitourinary 泌尿生殖系统Physical data/physical signs 一般资料/生理指标①Temperature (T.) 体温position: oral temperature 口温；axillary temperature 腋温；rectal temperature 肛温unit: Celsius, ℃; Fahrenheit, ℉Format: T 38 ℃(or 100.4℉)Pattern: The temperature is 38 ℃(or 100.4 ℉) taken by mouth/ by rectum/ by axilla.②Pulse (P.) 脉搏Format: P 80/min(or P80)Pattern: Pulse 80 per minute.The pulse numbered/beat/measured 80/min.③Respiration/ Respiratory Rate (R.) 呼吸Format: R 20/minCommon expressions:The respirations are 21 per minute.呼吸每分钟21次。