10.神经科英文病历语句

7
既往史







He has experienced …… The patient had a lengthy history of ……for……years treated with …… She has documented …… Within the past …… years, she has had …… …… year prior to this presentation, she had an brief episode of …… She describes a …… year history of ……, but denies …… the patient underwent ……for ……of…… Previous medical history included …… Present medications include …… gives a negative history for smoking, drug, and only occasional alcohol use.
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现病史


her balance deteriorated and on one occasion she fell in the shower. the …… became constant He saw an outside Neurologist who started him on ……（drugs） without improvement.
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现病史





…… have worsened in the last …… months having pain in …… radiating down to …… She was prescribed …… the acute onset of …… which was more marked on ……（doing）, but was present to a lesser extent when ……（doing）. …… have continued to progress to the present time. was graded as …… The residual weakness on the left had completely resolved and he reported no new weakness. her …… continued to deteriorate.
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既往史



Family history includes a grandfather with Alzheimer's disease The patients mother died of …… Family history was positive for …… and …… （disease） in his father, negative for …… （disease） . Family history revealed no history of …… She is married with two children The patient smoked …… packs a day in the past but quit completely …… years ago. He smoked one half pack of cigarettes per day for …… years, and he occasionally drank alcohol in moderation. does not smoke and is a social drinker.
颈“强”，是指“不易弯的” 正确表达：The neck was rigid

3
主诉





The patient is a …… year old female who presented （to ……） with （complaints of）……， accompanied by ……. the patient was admitted to ……with …… The patient is referred to ……for…… as well as …… She was unconscious for …… seconds, and was then confused for …… minutes. A 72-year-old man was admitted to …… because of ……
4现Leabharlann 史 she developed …… in ……. She went to ……，received …… to treat her …… Two days prior to admission, he noted an abrupt onset of ……. he began having difficulty ……（doing） when …… （doing） He had trouble …… （doing）, and subsequently in …… （doing） He then began to have problems …… （doing） have problems with…… got worse with increasing …… …… in …… gradually increased up to …… and to a lesser extent involved his …….
神经科英文病历语句
杜万良 北京天坛医院神经内科 2011.2.25
1
前言


用简练的语言汇报主要的病史、发现、诊断、 治疗。 英语的习惯表达。 照葫芦画瓢而已。
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举例

颈“软”，实际是指“无抵抗感，易弯曲的” 正确表达：The neck was supple 错误表达：The neck was soft