临床病症病历英文单词
Case Records表格式住院病历Biographical data:一般项目Name Age Sex Marital status Native place Race姓名年龄性别婚否籍贯民族Occupation Date of admission Informant职业入院日期病史叙述者History病史Chief complaint:主诉History of present illness:现病史Past history:既往史previous health status: well ordinary bad infectious diseases平素健康状况良好一般较差传染病史immunizations allergies: N Y clinical manifestation: allergen:预防接种史过敏史无有临床表现过敏原trauma history: surgery history:外伤史手术史Review of systems: (Tick if positive, cross out if negative. If positive, youshould write down your disease history and brief course of diagnose and therapy)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)Respiratory system:呼吸系统sore throat chronic cough sputum hemoptysis wheezing dyspneachest pain咽痛慢性咳嗽咳痰咯血哮喘呼吸困难胸痛Cardiovascular system:循环系统palpitation dyspnea on exertion hemoptysis syncope edema of lower limbs precordial pain hypertention心悸活动后气促咯血晕厥下肢水肿心前区痛高血压Digestive system:消化系统anorexia sour regurgitation belching nausea vomit abdominal distention abdominal pain食欲减退反酸嗳气恶心呕吐腹胀腹痛constipation diarrhea hematemesis melena hematochezia jaundice便秘腹泻呕血黑便便血黄疸Urinary system:泌尿系统lumbago frequent micturition urgent micturition urodynia dysuriahematuria nocturia腰痛尿频尿急尿痛排尿困难血尿夜尿polyuria oliguria facial edema多尿少尿面部水肿Hemopoietic system:造血系统fatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxis乏力头昏眼花牙龈出血皮下出血骨痛鼻衄Metabolic and endocrine system:代谢及内分泌系统excessive appetite anorexia sweets cold intolerance polydipsia polyuria tremor hands change of character食欲亢进食欲减退多汗畏寒多饮多尿双手震颤性格改变obvious obesity emaciation hairiness hair losing pigmentation change of sexual function amenorrhea显著肥胖消瘦多毛毛发脱落色素沉着性功能改变闭经Musculoskeleton system：肌肉骨骼系统floating arthralgia arthralgia swelling of joints deformities of joints myalgia atrophy of muscle游走性关节痛关节痛关节红肿关节变形肌肉痛肌肉萎缩Nervous system：神经系统dizziness headache vertigo syncope degeneration of memory visual disturbance insomnia头昏头痛眩晕晕厥记忆力减退视力障碍失眠disturbance of consciousness tremor spasm paralysis paresthesia意识障碍颤动抽搐瘫痪感觉异常Personal history:个人史birthplace occupation sexual history：N Y smoking：N Y about yrs average pieces/d出生地职业冶游史无有吸烟无有约年平均支/日ceased for yrs alcohol intake：N occasional frequent about yrs average ml/d others：戒烟年嗜酒无偶有经常约年平均 ml/日其它Marital history:婚姻史marrying age companion’s state of health结婚年龄配偶健康状况Menstruation and Childbearing history:月经及生育史lasting for daysmenarche age cycle days date of last period （age of menopause）初潮每次持续时间(天)周期(天) 末次月经时间 (绝经年龄)amount of flow: little normal large menstrual pain: N Y cycle: regular irregular经量少一般多痛经无有经期规则不规则pregnancy: times natural labor times abortions times premature delivery times stillbirths times妊娠次顺产胎流产胎早产胎死产胎difficult labor and its condition:难产及病情Family history: (pay attention to the congenital diseases and communicablediseases related to the patient)家族史(注意与患者现病有关的遗传病和传染性疾病)father: still alive illness died cause of death mother: still alive illness died cause of death父健在患病已故死因母健在患病已故死因siblings: others:兄弟姐妹子女及其他Physical examination体格检查Vital signs: temperature °C pulse /min respiration /min blood pressure / mmHg生命体征体温°C 脉搏次/分呼吸 /分血压/ mmHgGeneral Appearance:一般状况development: ortho-sthenic type asthenic type sthenic type nutrition: well fairly poor cachexia发育正常不良超常营养良好中等不良恶病质facial features: normal acute chronic others expressions: natural painful anxious dreadful indifferent面容无病容急性慢性病容其他表情自如痛苦忧虑恐惧淡漠position: active semi-recumbent others gait: normal abnormal体位自主半卧位其他步态正常不正常consciousness: aware somnolence confusion stupor coma delirium cooperation: well badly神志清楚嗜睡模糊昏睡昏迷谵妄配合检查合作不合作Skin, mucous membrane: color: normal red pale cyanosis yellow pigmentation rash: N Y(type and distribution )皮肤粘膜色泽正常潮红苍白紫绀黄染色素沉着皮疹无有(类型及分布 )subcutaneous hemorrhage: N Y(type and distribution ) hair: normal scattering losing(position )皮下出血无有(类型及分布 )毛发分布正常稀疏脱落(部位 )moisture and temperature: normal cold dry wet elasticity: normal reduced edema: N Y(position and degree)温度与湿度正常冷干湿弹性正常减退水肿无有(部位及程度 )hepatic palm: N Y spider angioma: N Y(position numbers ) others:肝掌无有蜘蛛痣无有(部位数目 ) 其他:Lymphnodes:淋巴结Superficial lymph nodes: non-swelling swelling(position andcharacteristics )全身浅表淋巴结无肿大肿大(部位及特征 )Head:头部cranium: size: normal large small deformity: N Y (oxycephaly squaredskull deforming skull)头颅大小: 正常大小畸型无有 (尖颅方颅变形颅)others: tenderness mass sunk(position )其他异常压痛包块凹陷(部位 )eyes: eyelid: normal edema ptosis trichiasis conjunctive: normal hyperemia edema hemorrhage眼眼睑正常水肿下垂倒睫结膜正常充血水肿出血eye ball: normal exophthalmos depression tremor motiondysfunction(left right )眼球正常突出凹陷震颤运动障碍 (左右 )sclera: normal yellow cornea: normal abnormal(left right ) pupils: equal roundness巩膜无黄染黄染角膜正常异常 (左右 ) 瞳孔等圆same size unequal left cm, right cm reaction to light: normal delay(left right )等大不等左 cm , 右 cm 对光反射正常迟钝(左右 )disappear(left right) others:消失 (左右 ) 其他ears: auricle: normal deformity fistula others(left right ) excretions of external canal: N Y(left right feature)耳耳廓正常畸型瘘管其他 (左右 ) 外耳道分泌物无有(左右性质)tenderness of mastoid: N Y (left right ) audition dysfunction: N Y (left right )乳突压痛无有(左右 ) 听力障碍无有 (左右 )nose: shape: normal abnormal( ) other abnormalities: N Y nasal ale flap obstruction excretions鼻外形正常异常( ) 其他异常无有鼻翼扇动鼻塞分泌物nasal sinus tenderness: N Y (position )鼻窦压痛无有 (部位 )mouth: lips: red cyanosis pale herpes fissure mucous: normal abnormal(pale bleeding)口唇红润发绀苍白疱疹皲裂粘膜: 正常异常 (苍白出血点)opening of parotid gland duct: normal abnormal (swelling pyogenic excretions )腮腺导管开口正常异常 (肿胀脓性分泌物 )tongue: normal abnormal(coverings tremor leaning to left or right) gums: normal swelling pus overflow舌正常异常 (舌苔伸舌震颤向左、右偏斜) 牙龈正常肿胀溢脓hemorrhage pigments lead line teeth: regular edentulous carious teeth false tooth出血色素沉着牙列齐缺牙龋牙义牙tonsils: pharynx: voice: normal hoarse扁桃体咽声音正常嘶哑Neck: resistance: N Y carotid artery pulsation: normal increaseddecreased(left right )颈部抵抗感无有颈动脉搏动正常增强减弱 (左右 )jugular vein: normal distention high distention trachea: middle deviationto (left right )颈静脉正常充盈怒张气管正中偏移 (向左向右 )hepatojugular reflux:（-）（+） thyroid: normal swelling degree symmetry dominance in one side:肝颈静脉回流征（-）（+）甲状腺正常肿大度对称侧为主spreading nodular: soft hard others: N Y (tenderness tremor bruits )弥漫性结节性质软质硬其他异常无有( 压痛震颤血管杂音)Chest: topography: normal barrel chest flat chest pigeon chest funnel chest bulging or retraction(left right )胸部胸廓正常桶状胸扁平胸鸡胸漏斗胸膨隆或凹陷(左右 )bulging in the precordial region tenderness of sternum心前区膨隆胸骨压痛breast: normal symmetrical abnormal: left right(gynecomastia mass tenderness excretions of nipples)乳房正常对称异常左右 (男子乳房发育包块压痛乳头分泌物)Lung:肺inspection: movement of respiration: normal abnormal: left right(increased decreased)视诊呼吸运动正常异常: 左右 (增强减弱)intercostal space: normal wide narrow(position )肋间隙正常增宽变窄 (部位 )palpation: vocal fremitus: normal abnormal: left right(increased decreased) pleural friction rubs: N Y(position )触诊语颤正常异常: 左右 (增强减弱) 胸膜摩擦感无有(部位 )percussion: resonance abnormal: dullness flatness hyperresonance tympany叩诊正常清音异常叩诊音浊音实音过清音鼓音lower borders: scapular line: right intercostal space left intercostal space肺下界肩胛线右肋间左肋间range of mobility: right cm, left cm移动度右 cm , 左 cmauscultation: breath: regular irregular听诊呼吸规整不规整breath sound: normal abnormal(feature, position )呼吸音正常异常(性质,部位描写 )rales: N Y : ronchi: sonorous sibilant罗音无有干性鼾音哨笛音moist rales: coarse medium fine rales crepitus湿性大中小水泡音捻发音(部位见图)vocal conduction: normal abnormal: reduced increased语音传导正常异常减弱增强pleural friction rubs: N Y(position )胸膜摩擦音无有(部位 )Heart:心inspection: bulging in precordial region: N Y apex impulse: normal unseen increased diffusing视诊心前区隆起无有心尖搏动正常未见增强弥散position: normal deviation(the distance from midclavicular line cm)心尖搏动位置正常移位 (距左锁中线内外 cm)other precordial pulsations: N Y(position )其他部位搏动无有(部位 )palpation: apex impulse: normal increased thrust unclear thrills: NY(position period )触诊心尖搏动正常增强抬举感触不清震颤无有(部位时期 )pericardial friction rubs: N Y心包摩擦感无有percussion: relative cardiac outline: normal shrink extant(right left)叩诊相对浊音界正常缩小扩大(右左) right(cm) intercostal space left(cm)右(cm) 肋间左(cm)锁中线距前正中线距离(cm)auscultation: heart rate bpm/min rhythm(regular irregular absolutelyirregular)听诊心率次/分心律 (齐不齐绝对不齐)heart sound: S1 normal increased decreased split S2 normal increaseddecreased split心音 S1 正常增强减弱分裂 S2 正常增强减弱分裂S3 N Y S4 N Y A2 P2S3 无有 S4 无有 A2 P2extra heart sound: N gallop(diastolic presystolic summation gallop)opening snap others额外心音无奔马律(舒张期收缩期前重叠性) 开瓣音其他murmurs: N Y (degree conduction)杂音无有 (图示并描述强度、传导)apical region aortic area pulmonary area tricuspid area心尖部主A瓣区肺A瓣区三尖瓣区left sternal border in 3nd intercostal space pericardial friction rubs: N Y胸骨左缘第3肋间心包摩擦音无有Peripheral vessels: normal pistol shot: N Y Duroziez sign: N Y water hammer pulse: N Y周围血管无异常血管征枪击音无有杜柔双重音无有水冲脉无有capillary pulsation：N Y pulse deficit：N Y paradoxical pulse：N Y pulsus alternans：N Y other：毛细血管搏动无有脉搏短绌无有奇脉无有交替脉无有其他Abdoman：腹部inspection: shape：normal distention frog belly cm scaphoid abdomenapical belly视诊外形正常膨隆蛙腹(腹围 cm) 舟状腹尖腹gastric pattern intestinal pattern peristalsis abdominal respiration: exist disappear胃型肠型蠕动波腹式呼吸存在消失umbilicus: normal protruding excretions脐正常凸出分泌物others: N Y(venous distention of abdomen purple striae surgical scars hernia)其他异常无有 (腹壁静脉曲张条纹手术疤痕疝)palpation: soft muscle tension position tenderness: N Y rebound tenderness: N Y触诊柔软腹肌紧张部位压痛无有反跳痛无有fluid thrill: N Y succusion splash: N Y masses: NY(position size )液波震颤无有振水音无有腹部包块无有(部位大小见图示)description of feature:特征描述liver: not touched be touched: subcostal cm肝未触及可触及: 肋下 cmdescription of feature:特征描述gallbladder: not touched be touched: size cm胆囊未触及可触及大小 cmtenderness: N Y Murphy's sign: (+) (-)压痛无有 Murphy征阳性阴性spleen: not touched be touched: from costal margin cm脾: 未触及可触及肋下 cmdescription of feature:特征描述kidney: not touched be touched: size consistency tenderness mobility肾未触及可触及大小硬度压痛移动度tenderness of ureters: N Y(position )输尿管压痛点无有(部位 )percussion: borders of liver dullness(exist shrink obliteration)叩诊肝浊音界 (存在缩小消失)upper border of liver: on right midclavicular line intercostal space肝上界位于右锁骨中线肋间shifting dullness: N Y tenderness in renal region: N Y(right left )移动性浊音无有肾区叩痛无有(左右 )auscultation: gurgling sound: normal increased decreased disappear vessel bruits: N Y(position )听诊肠鸣音正常亢进减弱消失血管杂音无有(部位 )Genitalia: not examined normal abnormal:生殖器未查正常异常Rectum and Anus: not examined normal abnormal:肛门直肠未查正常异常Spine and Extremities:脊柱四肢spine: normal deformities(lateral anterior posterior protruding)脊柱正常畸型 ( 侧前后凸)acanthi: tenderness pain at percussion(position ) mobility: normal restricted棘突压痛叩痛 (部位 ) 活动度正常受限limbs: normal abnormal deformity swelling of joints joints stiffness tenderness of muscles四肢正常异常畸型关节红肿关节强直肌肉压痛atrophy of muscles venous distention of lower limbs(position and feature ) acropachy肌肉萎缩下肢静脉曲张 (部位及特征 ) 杵状指趾Nervous System:神经系统muscle tone(normal increase decrease paratonia) myodynamia（0 I IIIII IV V）肌张力( 正常增高减弱强直) 肌力 (0 I II III IV V级)paralysis of limbs: N Y(left right upper lower)肢体瘫痪无有 (左右上下)reflex: abdominal wall reflex(normal ) biceps reflex：left(normal )right(normal )神经反射腹壁反射 (正常 ) 肱二头肌反射左(正常 )右(正常 )triceps reflex: left(normal ) right(normal ) patellar reflex:left(normal ) right (normal )肱三头肌反射左(正常 )右(正常 ) 膝反射左(正常 ) 右(正常 )achilles reflex: left(normal ) right (normal )跟腱反射左(正常 )右(正常 )Hoffmann sign: left (+) (-) right (+) (-) Babinski sign: left (+) (-)right(+) (-) Oppenheim sign: left (+) (-) right(+) (-)Hoffmann征左(+) (-) 右 (+) (-) Babinski征左(+) (-) 右 (+) (-) Oppenheim征左(+) (-) 右 (+) (-) Kernig sign: left (+) (-) right (+) (-) Brudzinski sign: left (+) (-) right(+) (-) others：Kernig征左(+) (-) 右(+) (-) Brudzinski征左 (+) (-) 右 (+) (-) 其他Laboratory findings实验室及器械检查结果(The important laboratory examinations，X-ray，ECG and other result are included)，No. X-ray(重要的化验、X线、心电图及其它有关化验) X线片号Abstract病历摘要Diagnosis(Impressions)入院诊断Recorder(Signature)病史记录者（签字）Date of record记录日期。
(完整版)常见疾病英文单词
常见疾病英文单词cough 咳嗽asthma 哮喘pneumonia 肺炎dermatitis皮炎gastritis 胃炎hepatitis 肝炎appendicitis 盲肠炎arrhythmia 心律不齐diarrhoea 痢疾acne 粉刺freckle/ephelis 痣，雀斑endemic 水土不服sprain 扭伤stupor 昏迷bruise 淤伤scalding烫伤shuddering 发抖inflammation 炎症acute 急症chronic 慢性病congenital 先天性病nausea恶心vomit 呕吐freckle/ephelis 痣，雀斑acne 粉刺痢疾,腹泻/拉肚子diarrhea，diarrhoea，laxness，scour，tummyTummy 胃, 肚子(常指旅游者患的)腹痛, 腹泻flu 流感diarrhoea 痢疾quarantine 检疫vaccinate 打疫苗endemic 水土不服relapse 复发症casualty急症stupor 昏迷sprain 扭伤scalding烫伤graze 擦伤scratch 搔挠trauma 外伤bruise 淤伤fracture骨折dislocation 脱臼tinnitus 耳鸣trachoma 沙眼colour blindness 色盲nearsightedness/myopia近视astigmatism 散光gingivitis 牙龈炎cavity 龋齿fever 发烧discomfort/disorder 不适malnutrition 营养不良incubation 潜伏期asthenia 虚弱poisoning 中毒fatigue 疲劳heat stroke 中暑itching 发痒ache/pain 痛tetanus 破伤风night sweat 盗汗chill 打冷颤pale 脸色发白Disease 疾病anemia, anaemia 贫血angina pectoris 心绞痛appendicitis 阑尾炎arthritis 关节炎bronchitis 支气管炎cancer 癌catarrh 卡他, 粘膜炎chicken pox, varicella 水痘cholera 霍乱cold 感冒, 伤风, 着凉(head) cold 患感冒diabetes 糖尿病diphtheria 白喉eczema 湿疹epilepsy 癫痫erysipelas 丹毒gangrene 坏疽German measles, rubella 风疹gout 痛风headache 头痛hemiplegy, hemiplegia 偏瘫, 半身不遂icterus, jaundice 黄疸indigestion 消化不良influenza, flu 流感insanity 精神病leukemia 白血病malaria 疟疾malnutrition 营养不良Malta fever 马耳他热, 波状热measles 麻疹migraine, splitting headache 偏头痛miocardial infarction 心肌梗塞mumps 流行性腮腺炎neuralgia 神经痛neurasthenia 神经衰弱paralysis 麻痹peritonitis 腹膜炎pharyngitis 咽炎phtisis 痨病, 肺结核pneumonia 肺炎poliomyelitis 脊髓灰质炎rabies 狂犬病rheumatism 风湿病rickets, rachitis 佝偻病scabies, itch 疥疮scarlet fever 猩红热sciatica 坐骨神经痛sclerosis 硬化septicemia, septicaemia 败血病sinusitis 窦炎smallpox 天花swamp fever 沼地热syncope 晕厥syphilis 梅毒tetanus 破伤风thrombosis 血栓形成torticollis, stiff neck 斜颈tuberculosis 结核病tumour,tumor 瘤typhus 斑疹伤寒urticaria, hives 荨麻疹whooping cough 百日咳yellow fever 黄热病zona, shingles 带状疮疹。
医学病历英文缩写
医学病历英文缩写aa.-of each[各]Ab.-antibody[抗体]abd.-abdomen[腹部]ABG-arterial blood gas[动脉血气]abn.-abnormal[异常]ABp-arterial blood pressure[动脉压]Abs.-absent[无]abstr.-abstract[摘要]a.c.-before meals[饭前]Ach.-actylcholine[乙酰胆碱]ACH.-adrenal cortical hormone[肾上腺皮质激素] ?ACT.-active coagulative time[活化凝血时间] ?ACTH.-adrenocorticotripic[促肾上腺皮质激素] ?ad.(add.)-adde[加]ad effect.-ad effectum [直到有效]ADH.-antidiuretic hormone[抗利尿激素]ad lib-at liesure[随意]adm.(admin)-adminstration[给药]ad us est.-for external use[外用]af.-atrial fibrillation[房颤]aF.-atrial flutter[房扑]A/G ratio.-albumin-globulin ratio[白-球蛋白比] ?AIDS.-acquired immune deficiency syndrome[爱滋病] ?al.-left ear[左耳] alb.-albumin[白蛋白]AM.-before noon[上午]amb.-ambulance[救护车]amp.(ampul)-ampoule[安瓿]ANA.-anesthesia[麻醉]anal.-analgesic[镇痛药]ap.-before dinner[饭前]appr.(approx.)-approximately [大约] AR.-aortic regurgitation[主闭]AS.-aortic stenosis[主狭]ASA.-aspirin[阿斯匹林]ASD.-atrial septal defect[房缺]AST.-aspartate transaminase[谷草转氨酶] atm.(atmos.)-atomsphere[大气压] ATS.-antitetanic serum[抗破伤风血清] av.-average[平均]Ba.-Barium[钡]BBT.-basal body temperature[基础体温] BCG.-bacille Calmette- Guerin[卡介苗] biblio.-biliography[参考文献]bid.-twice a day[每日二次]b.m.-basal metabolism[基础代]Bp.-blood pressure[血压]bpm-baets per minute[次/分]BS.-blood sugar[血糖]BW.-body weight[体重]C.- centigrade[摄氏温度计]CA.-carcinoma[癌]Cal.-cancer[癌]Cal. –calorie[卡]Cap. –capsule[囊]C.B.C-complete blood count[血常规] CC.-chief complaint[主诉]CC. list.-critical condition list[病危通知单] CCU.- Coronary care unit[冠心病监护室] CD.-caesarean delivered[剖腹产]CDC.-calculated date of confinement[预产期]CEA.-carcinoembryonic antigen[癌胚抗原]CG.-control group[对照组]CK.-creatine kinase[肌酸激酶]Cl.-centilitre[毫开]cm.-centimetre[毫米]医学全在线www.med126.CNS.-central nervous system[中枢神经系统]Co.-compound[复方]contra.-contraindicated[禁忌]CT.- computerized tomography[计算机断层扫描]C.V-curriculum vitae[简历]DBp-diastolic blood pressure[舒压]DD.- differential diagnosis[鉴别诊断]dept.-department[科]diag.-diagonsis[诊断]DIC-disseminate intravascular coagulation[弥漫性血管凝血] ?dl.-deciliter[分升]DM.-diabetic mellitus[糖尿病]DM.-diastolic murmur[舒期杂音]D.O.A-dead on arrival[到达时已死亡]DOB.-date of birth[出生日期]Dr.-doctor[医生]DIW.-dextrose in water[葡萄糖液]D-5-W,-5% dextrose in water[5%葡萄糖液]DU-duodenal ulcer[十二指肠溃疡]ECG.(EKG.)- electrocardiograph[心电图]ECHO .-echogram[超声]EDD.(EDC)-expected date of delivery (confinement)[预产期] ENT. –ears, nose and throat[五官科]EMG. –electromyogram[肌电图]ER. –emergency room[急诊室]et al.-and elsewhere[等等]etc. –and so forth[等等]F.(Fahr.)-Fahrenheit [华氏]F- Female[女性]F.B.S.- fasting blood sugar[空腹血糖]FDP.-fibrinogen degradation products[纤维蛋白原降解产物] FFA. –free fatty acid[游离脂肪酸]FUO. –fever of unknown origin[不明原因发热]FX. –fracture [骨折]GH. –growth hormone[生长素]GI.- gastrointestinal[消化]GITS. –gastrointestinal therapy system[胃肠治疗系统]gtt. –drops[滴]GU.- gastric ulcer[胃溃疡]Hb. –hemoglobin[血红蛋白]HBp.-high blood pressure[高血压]HCG. –human choroionic gonadotropic hormone[人绒毛膜促性腺激素] ?HDL.- high density lipoprotein[高密度脂蛋白] HR.-heart rate[心率]ht.-height[身高]HTN.-hypertension[高血压]Hx.-history [病历]Hypo.-hypodermic injection[皮下注射]IABP.-intra –aortic balloon pacing[主动脉囊反搏]I/O.-intake and output [进出量]ICU. –intensive care unit[重症监护病房]ie. –that is [即]Ig. –immunoglobulin[免疫球蛋白]Im. –iutramuscular[肌的]INH.- inhalation[吸入]INH.- isoniazid[异烟肼]Inj.- injection[注射]Int.- intern[实习生]IP.- in-patient[住院病入]Iu.- international unit[国防单位]IV.-intravenously[静脉]J.- joule[焦耳]该文章自医学全在线：.med126./yingyu/2008/20572.shtmlK.U.B- Kidney,ureter and bladder[肾、输尿管和膀胱]LBp.-low blood pressure [低血压]LC. –laparoscopic cholecystectomy[腹腔镜胆囊切除术]LDL.-Low density lipoprotein[低密度脂蛋白]Liq. –liquid[液体]LMP.- last menstrual period[未次月经]LP. –lumbar puncture[腰穿]M. –male[男性]MCD.-mean corpuscular diameter[平均红细胞直径]MCH.-mean corpuscular hemoglobin[平均红细胞血红蛋白量] MCHC.-mean corpuscular hemoglobin concentration[平均红细胞血红蛋白浓度] ?MCV.-mean corpuscular volume[平均红细胞体积]MI.-myocardial infarction[心梗]min.-minute[分]mixt。
临床病症病历英文单词
Case Records表格式住院病历Biographical data:一般项目Name Age Sex Marital status Native placeRace姓名年龄性别婚否籍贯民族Occupation Date of admission Informant职业入院日期病史叙述者History病史Chief complaint:主诉History of present illness:现病史Past history:既往史previous health status: well ordinary bad infectious diseases平素健康状况良好一般较差传染病史immunizations allergies: N Y clinical manifestation: allergen:预防接种史过敏史无有临床表现过敏原trauma history: surgery history:外伤史手术史Review of systems: (Tick if positive, cross out if negative. If positive, youshould write down your disease history and brief course of diagnose and therapy)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)Respiratory system:呼吸系统sore throat chronic cough sputum hemoptysis wheezing dyspnea chestpain咽痛慢性咳嗽咳痰咯血哮喘呼吸困难胸痛Cardiovascular system:循环系统palpitation dyspnea on exertion hemoptysis syncope edema of lower limbsprecordial pain hypertention心悸活动后气促咯血晕厥下肢水肿心前区痛高血压Digestive system:消化系统anorexia sour regurgitation belching nausea vomit abdominal distentionabdominal pain食欲减退反酸嗳气恶心呕吐腹胀腹痛constipation diarrhea hematemesis melena hematochezia jaundice便秘腹泻呕血黑便便血黄疸Urinary system:泌尿系统lumbago frequent micturition urgent micturition urodynia dysuria hematurianocturia腰痛尿频尿急尿痛排尿困难血尿夜尿polyuria oliguria facial edema多尿少尿面部水肿Hemopoietic system:造血系统fatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhageostealgia epistaxis乏力头昏眼花牙龈出血皮下出血骨痛鼻衄Metabolic and endocrine system: 代谢及内分泌系统excessive appetite anorexia sweets cold intolerance polydipsia polyuriatremor hands change of character食欲亢进食欲减退多汗畏寒多饮多尿双手震颤性格改变obvious obesity emaciation hairiness hair losing pigmentation change ofsexual function amenorrhea显著肥胖消瘦多毛毛发脱落色素沉着性功能改变闭经Musculoskeleton system：肌肉骨骼系统floating arthralgia arthralgia swelling of joints deformities of joints myalgia atrophy of muscle游走性关节痛关节痛关节红肿关节变形肌肉痛肌肉萎缩Nervous system：神经系统dizziness headache vertigo syncope degeneration of memory visual disturbance insomnia头昏头痛眩晕晕厥记忆力减退视力障碍失眠disturbance of consciousness tremor spasm paralysis paresthesia意识障碍颤动抽搐瘫痪感觉异常Personal history: 个人史birthplace occupation sexual history：N Y smoking：N Y about yrs average pieces/d出生地职业冶游史无有吸烟无有约年平均支/日ceased for yrs alcohol intake：N occasional frequent about yrs average ml/d others：戒烟年嗜酒无偶有经常约年平均 ml/日其它Marital history:婚姻史marrying age companion’s state of health结婚年龄配偶健康状况Menstruation and Childbearing history:月经及生育史lasting for daysmenarche age cycle days date of last period （age of menopause）初潮每次持续时间(天) 周期(天) 末次月经时间 (绝经年龄) amount of flow: little normal large menstrual pain: N Y cycle: regular irregular经量少一般多痛经无有经期规则不规则pregnancy: times natural labor times abortions times premature delivery times stillbirths times妊娠次顺产胎流产胎早产胎死产胎difficult labor and its condition: 难产及病情Family history: (pay attention to the congenital diseases and communicable diseases related to the patient)家族史(注意与患者现病有关的遗传病和传染性疾病)father: still alive illness died cause of death mother: still alive illness died cause of death父健在患病已故死因母健在患病已故死因siblings: others:兄弟姐妹子女及其他Physical examination体格检查Vital signs: temperature °C pulse /min respiration /min blood pressure / mmHg生命体征体温°C 脉搏次/分呼吸 /分血压/ mmHgGeneral Appearance:一般状况development: ortho-sthenic type asthenic type sthenic type nutrition: well fairly poor cachexia发育正常不良超常营养良好中等不良恶病质facial features: normal acute chronic others expressions: natural painful anxious dreadful indifferent面容无病容急性慢性病容其他表情自如痛苦忧虑恐惧淡漠position: active semi-recumbent others gait: normal abnormal体位自主半卧位其他步态正常不正常consciousness: aware somnolence confusion stupor coma delirium cooperation: well badly神志清楚嗜睡模糊昏睡昏迷谵妄配合检查合作不合作Skin, mucous membrane: color: normal red pale cyanosis yellow pigmentation rash: N Y(type and distribution ) 皮肤粘膜色泽正常潮红苍白紫绀黄染色素沉着皮疹无有(类型及分布 )subcutaneous hemorrhage: N Y(type and distribution ) hair: normal scattering losing(position )皮下出血无有(类型及分布 )毛发分布正常稀疏脱落(部位)moisture and temperature: normal cold dry wet elasticity: normal reduced edema:N Y(position and degree)温度与湿度正常冷干湿弹性正常减退水肿无有(部位及程度 ) hepatic palm: N Y spider angioma: N Y(position numbers ) others:肝掌无有蜘蛛痣无有(部位数目 ) 其他:Lymphnodes:淋巴结Superficial lymph nodes: non-swelling swelling(position and characteristics )全身浅表淋巴结无肿大肿大(部位及特 )Head:头部cranium: size: normal large small deformity: N Y (oxycephaly squared skull deforming skull)头颅大小: 正常大小畸型无有 (尖颅方颅变形颅) others: tenderness mass sunk(position )其他异常压痛包块凹陷(部位 )eyes: eyelid: normal edema ptosis trichiasis conjunctive: normal hyperemia edema hemorrhage眼眼睑正常水肿下垂倒睫结膜正常充血水肿出血eye ball: normal exophthalmos depression tremor motion dysfunction(left right )眼球正常突出凹陷震颤运动障碍 (左右 )sclera: normal yellow cornea: normal abnormal(left right ) pupils: equal roundness巩膜无黄染黄染角膜正常异常 (左右 ) 瞳孔等圆same size unequal left cm, right cm reaction to light: normal delay(left right )等大不等左 cm , 右 cm 对光反射正常迟钝(左右 ) disappear(left right) others:消失 (左右 ) 其他ears: auricle: normal deformity fistula others(left right ) excretions of external canal: N Y(left right feature)耳耳廓正常畸型瘘管其他 (左右 ) 外耳道分泌物无有(左右性质)tenderness of mastoid: N Y (left right ) audition dysfunction: N Y (left right )乳突压痛无有(左右 ) 听力障碍无有 (左右 )nose: shape: normal abnormal( ) other abnormalities: N Y nasal ale flap obstruction excretions鼻外形正常异常( ) 其他异常无有鼻翼扇动鼻塞分泌物nasal sinus tenderness: N Y (position )鼻窦压痛无有 (部位 )mouth: lips: red cyanosis pale herpes fissure mucous: normal abnormal(pale bleeding)口唇红润发绀苍白疱疹皲裂粘膜: 正常异常 (苍白出血点) opening of parotid gland duct: normal abnormal (swelling pyogenicexcretions )腮腺导管开口正常异常 (肿胀脓性分泌物 ) tongue: normal abnormal(coverings tremor leaning to left or right) gums: normal swelling pus overflow舌正常异常 (舌苔伸舌震颤向左、右偏斜) 牙龈正常肿胀溢脓hemorrhage pigments lead line teeth: regular edentulous carious teeth false tooth出血色素沉着牙列齐缺牙龋牙义牙tonsils: pharynx: voice: normal hoarse扁桃体咽声音正常嘶哑Neck: resistance: N Y carotid artery pulsation: normal increased decreased(left right )颈部抵抗感无有颈动脉搏动正常增强减弱 (左右 ) jugular vein: normal distention high distention trachea: middle deviation to (left right )颈静脉正常充盈怒张气管正中偏移 (向左向右 ) hepatojugular reflux:（-）（+）thyroid: normal swelling degree symmetry dominance in one side:肝颈静脉回流征（-）（+）甲状腺正常肿大度对称侧为主spreading nodular: soft hard others: N Y (tenderness tremor bruits )弥漫性结节性质软质硬其他异常无有( 压痛震颤血管杂音)Chest: topography: normal barrel chest flat chest pigeon chest funnel chest bulging or retraction(left right )胸部胸廓正常桶状胸扁平胸鸡胸漏斗胸膨隆或凹陷(左右 )bulging in the precordial region tenderness of sternum心前区膨隆胸骨压痛breast: normal symmetrical abnormal: left right(gynecomastia mass tenderness excretions of nipples)乳房正常对称异常左右 (男子乳房发育包块压痛乳头分泌物) Lung:肺inspection: movement of respiration: normal abnormal: left right(increased decreased)视诊呼吸运动正常异常: 左右 (增强减弱) intercostal space: normal wide narrow(position )肋间隙正常增宽变窄 (部位 )palpation: vocal fremitus: normal abnormal: left right(increased decreased) pleural friction rubs: N Y(position )触诊语颤正常异常: 左右 (增强减弱) 胸膜摩擦感无有(部位 ) percussion: resonance abnormal: dullness flatness hyperresonance tympany叩诊正常清音异常叩诊音浊音实音过清音鼓音lower borders: scapular line: right intercostal space left intercostal space 肺下界肩胛线右肋间左肋间range of mobility: right cm, left cm移动度右 cm , 左 cmauscultation: breath: regular irregular听诊呼吸规整不规整breath sound: normal abnormal(feature, position )呼吸音正常异常(性质,部位描写 )rales: N Y : ronchi: sonorous sibilant罗音无有干性鼾音哨笛音moist rales: coarse medium fine rales crepitus湿性大中小水泡音捻发音(部位见图)vocal conduction: normal abnormal: reduced increased语音传导正常异常减弱增强pleural friction rubs: N Y(position )胸膜摩擦音无有(部位 )Heart:心inspection: bulging in precordial region: N Y apex impulse: normal unseen increased diffusing视诊心前区隆起无有心尖搏动正常未见增强弥散position: normal deviation(the distance from midclavicular line cm)心尖搏动位置正常移位 (距左锁中线内外 cm)other precordial pulsations: N Y(position )其他部位搏动无有(部位 )palpation: apex impulse: normal increased thrust unclear thrills: NY(position period )触诊心尖搏动正常增强抬举感触不清震颤无有(部位时期 )pericardial friction rubs: N Y心包摩擦感无有percussion: relative cardiac outline: normal shrink extant(right left)叩诊相对浊音界正常缩小扩大(右左)right(cm) intercostal space left(cm)右(cm) 肋间左(cm)锁中线距前正中线距离(cm)auscultation: heart rate bpm/min rhythm(regular irregular absolutely irregular)听诊心率次/分心律 (齐不齐绝对不齐)heart sound: S1 normal increased decreased split S2 normal increased decreased split心音 S1 正常增强减弱分裂 S2 正常增强减弱分裂S3 N Y S4 N Y A2 P2S3 无有 S4 无有 A2 P2extra heart sound: N gallop(diastolic presystolic summation gallop) openingsnap others额外心音无奔马律(舒张期收缩期前重叠性) 开瓣音其他murmurs: N Y (degree conduction)杂音无有 (图示并描述强度、传导)apical region aortic area pulmonary area tricuspid area心尖部主A瓣区肺A瓣区三尖瓣区left sternal border in 3nd intercostal space pericardial friction rubs: N Y胸骨左缘第3肋间心包摩擦音无有Peripheral vessels: normal pistol shot: N Y Duroziez sign: N Y water hammerpulse: N Y周围血管无异常血管征枪击音无有杜柔双重音无有水冲脉无有capillary pulsation：N Y pulse deficit：N Y paradoxical pulse：N Y pulsus alternans：N Y other：毛细血管搏动无有脉搏短绌无有奇脉无有交替脉无有其他Abdoman：腹部inspection: shape：normal distention frog belly cm scaphoid abdomenapical belly视诊外形正常膨隆蛙腹(腹围 cm) 舟状腹尖腹gastric pattern intestinal pattern peristalsis abdominal respiration: exist disappear胃型肠型蠕动波腹式呼吸存在消失umbilicus: normal protruding excretions脐正常凸出分泌物others: N Y(venous distention of abdomen purple striae surgical scars hernia)其他异常无有 (腹壁静脉曲张条纹手术疤痕疝)palpation: soft muscle tension position tenderness: N Y rebound tenderness:N Y触诊柔软腹肌紧张部位压痛无有反跳痛无有fluid thrill: N Y succusion splash: N Y masses: N Y(position size )液波震颤无有振水音无有腹部包块无有(部位大小见图示) description of feature:特征描述liver: not touched be touched: subcostal cm肝未触及可触及: 肋下 cmdescription of feature:特征描述gallbladder: not touched be touched: size cm胆囊未触及可触及大小 cmtenderness: N Y Murphy's sign: (+) (-)压痛无有 Murphy征阳性阴性spleen: not touched be touched: from costal margin cm脾: 未触及可触及肋下 cmdescription of feature:特征描述kidney: not touched be touched: size consistency tenderness mobility肾未触及可触及大小硬度压痛移动度tenderness of ureters: N Y(position )输尿管压痛点无有(部位 )percussion: borders of liver dullness(exist shrink obliteration)叩诊肝浊音界 (存在缩小消失)upper border of liver: on right midclavicular line intercostal space肝上界位于右锁骨中线肋间shifting dullness: N Y tenderness in renal region: N Y(right left )移动性浊音无有肾区叩痛无有(左右 )auscultation: gurgling sound: normal increased decreased disappear vessel bruits: N Y(position )听诊肠鸣音正常亢进减弱消失血管杂音无有(部位 ) Genitalia: not examined normal abnormal:生殖器未查正常异常Rectum and Anus: not examined normal abnormal:肛门直肠未查正常异常Spine and Extremities:脊柱四肢spine: normal deformities(lateral anterior posterior protruding)脊柱正常畸型 ( 侧前后凸)acanthi: tenderness pain at percussion(position ) mobility: normal restricted棘突压痛叩痛 (部位 ) 活动度正常受限limbs: normal abnormal deformity swelling of joints joints stiffness tenderness of muscles四肢正常异常畸型关节红肿关节强直肌肉压痛atrophy of muscles venous distention of lower limbs(position and feature ) acropachy肌肉萎缩下肢静脉曲张 (部位及特征 ) 杵状指趾Nervous System:神经系统muscle tone(normal increase decrease paratonia) myodynamia（0 I II III IV V）肌张力( 正常增高减弱强直) 肌力 (0 I II III IV V级) paralysis of limbs: N Y(left right upper lower)肢体瘫痪无有 (左右上下)reflex: abdominal wall reflex(normal ) biceps reflex：left(normal )right(normal )神经反射腹壁反射 (正常 ) 肱二头肌反射左(正常 )右(正常 ) triceps reflex: left(normal ) right(normal ) patellar reflex: left(normal ) right (normal )肱三头肌反射左(正常 )右(正常 ) 膝反射左(正常 ) 右(正常 ) achilles reflex: left(normal ) right (normal )跟腱反射左(正常 )右(正常 )Hoffmann sign: left (+) (-) right (+) (-) Babinski sign: left (+) (-) right(+) (-) Oppenheim sign: left (+) (-) right(+) (-)Hoffmann征左(+) (-) 右 (+) (-) Babinski征左(+) (-) 右 (+) (-) Oppenheim 征左(+) (-) 右 (+) (-) Kernig sign: left (+) (-) right (+) (-) Brudzinski sign: left (+) (-) right(+) (-) others：Kernig征左(+) (-) 右(+) (-) Brudzinski征左 (+) (-) 右 (+) (-) 其他Laboratory findings实验室及器械检查结果(The important laboratory examinations，X-ray，ECG and other result are included)，No. X-ray(重要的化验、X线、心电图及其它有关化验) X线片号Abstract病历摘要Diagnosis(Impressions)入院诊断Recorder(Signature)病史记录者（签字）Date of record记录日期。
临床试验常见英文缩写
临床试验常见英文缩写ADR（Adverse drug reaction）不良反应AE（Adverse event）不良事件SAE（Serious Adverse Event）严重不良事件CRF（Case report form/case record form）病例报告表CRO（Contract research organization）合同研究组织EC（Ethics Committee）伦理委员会GCP（Good clinical practice）药品临床试验管理规范EDC（Electronic data capture）电子数据采集IB（Investigator's Brochure）研究者手册ND (Not Done) 未做NA (Not Applicable) 不适用UK (Unknown) 未知PI（Principal investigator ）主要研究者Sub-I(Sub-investigator) 助理研究者QA(Quality assurance) 质量保证QC(Quality control) 质量控制SDV（Source data verification）原始资料核对SD（Source data）原始数据SD(Source document ) 原始文件SFDA 国家食品药品监督管理局SOP(Standard operating procedure) 标准操作规程IRB 机构审查委员会ICF(Informed Consent Form) 知情同意书TMF（trial master file）研究管理文件夹临床试验常见英文单词A•Active control ,AC 阳性对照，活性对照阳性对照，活性对照•Adverse drug reaction ,ADR 药物不良反应药物不良反应•Adverse event ,AE 不良事件•Approval 批准•Assistant investigator 助理研究者•Audit 稽查•Audit report 稽查报告•Auditor 稽查员B•Bias 偏性，偏倚•Blank control 空白对照•Blinding/masking 盲法，设盲•Block 层C•Case history 病历•Case report form/case record form ,CRF 病例报告表，病例记录表•Clinical study 临床研究•Clinical trial 临床试验•Clinical trial application ,CTA 临床试验申请•Clinical trial exemption ,CTX 临床试验免责•Clinical trial protocol ,CTP 临床试验方案•Clinical trial/study report 临床试验报告•COA(药品检测报告)•Co-investigator 合作研究者•Comparison 对照•Compliance 依从性•Computer-assisted trial design ,CATD 计算机辅助试验设计•Contract research organization ,CRO 合同研究组织•Contract/agreement 协议/合同•Coordinating committee 协调委员会•Coordinating investigator 协调研究者•Cross-over study 交叉研究•Cure 痊愈•CTRB 临床试验文件夹D•Documentation 记录/文件•Dose-reaction relation 剂量—反应关系•Double blinding 双盲•Double dummy technique 双盲双模拟技术E•Electronic data capture ,EDC 电子数据采集系统•Electronic data processing ,EDP 电子数据处理系统•Endpoint criteria/measurement 终点指标•Essential documentation 必需文件•Excellent 显效•Exclusion criteria 排除标准F•Failure 无效，失败•Final report 总结报告•Final point 终点•Forced titration 强制滴定G&H•Global 全球•Generic drug 通用名药•Good clinical practice ,GCP 药物临床试验质量管理规定•Good manufacture practice ,GMP 药品生产质量管理规范•Good non-clinical laboratory practice ,GLP 药物非临床研究质量管理规范•Health economic evaluation ,HEV 健康经济学评价•Hypothesis testing 假设检验I•Improvement 好转•Inclusion criteria 入选标准•Independent ethics committee ,IEE 独立伦理委员会•Information gathering 信息收集•Informed consent form ,ICF 知情同意书•Informed consent ,IC 知情同意•Initial meeting 启动会议•Inspection 视察/检查•Institution inspection 机构检查•Institutional review board ,IBR 机构审查委员会•Intention to treat 意向治疗•Interactive voice response system ,IVRS 互动式语音应答系统•International Conference on Harmonization ,ICH 国际协调会议•Investigational new drug ,IND 新药临床研究•Investigational product 试验药物•Investigator 研究者•Investigator’s brochure ,IB 研究者手册L•Local 局部M&N•Marketing approval/authorization 上市许可证•Matched pair 匹配配对•Monitor 监查员•Monitoring 监查•Monitoring report 监查报告•Multi-center trial 多中心试验•New chemical entity ,NCE 新化学实体•New drug application ,NDA 新药申请•Non-clinical study 非临床研究O•Obedience 依从性•Optional titration 随意滴定•Original medical record 原始医疗记录•Outcome 结果•Outcome assessment 结果指标评价•Outcome measurement 结果指标P•Patient file 病人指标•Patient history 病历•Placebo 安慰剂•Placebo control 安慰剂对照•Preclinical study 临床前研究•Principle investigator ,PI 主要研究者•Product license ,PL 产品许可证•Protocol 试验方案•Protocol amendment 方案补正Q&R•Quality assurance ,QA 质量保证•Quality assurance unit ,QAU 质量保证部门•Quality control ,QC 质量控制•Randomization 随机•Regulatory authorities ,RA 监督管理部门•Replication 可重复•Run in 准备期S•Sample size 样本量，样本大小•Serious adverse event ,SAE 严重不良事件•Serious adverse reaction ,SAR 严重不良反应•Seriousness 严重性•Severity 严重程度•Simple randomization 简单随机•Single blinding 单盲•Site audit 试验机构稽查•Source data ,SD 原始数据•Source data verification ,SDV 原始数据核准•Source document ,SD 原始文件•Sponsor 申办者•Sponsor-investigator 申办研究者•Standard operating procedure ,SOP 标准操作规程•Statistical analysis plan ,SAP 统计分析计划•Study audit 研究稽查•Subgroup 亚组•Sub-investigator 助理研究者•Subject 受试者•Subject diary 受试者日记•Subject enrollment 受试者入选•Subject enrollment log 受试者入选表•Subject identification code ,SIC 受试者识别代码•Subject recruitment 受试者招募•Subject screening log 受试者筛选表•System audit 系统稽查T&U•Trial error 试验误差•Trial master file 试验总档案•Trial objective 试验目的•Trial site 试验场所•Triple blinding 三盲•Unblinding 破盲•Unexpected adverse event ,UAE 预料外不良事件V&W•Variability 变异•Visual analogy scale 直观类比打分法•Vulnerable subject 弱势受试者•Wash-out 清洗期•Well-being 福利，健康EDC 系统常见英文缩写•1.SCR (screening) 筛选•2.DOV (date of visit) 访视第一天•3.ELIG ( ELIGIBILITY ) 入排合格•4.DEM ( DEMOGRAPHY )人口统计学•5.MEDSX (medical history) 既往史•MHX1 : CANCER RELATED CURRENT MEDICAL CONDITIONS 该肿瘤手术史及肿瘤相关症状•MHX2 : NON-CANCER RELATED MEDICAL CONDITIONS•与该肿瘤无关的病史•6.VS /VITALS ( VITAL SIGNS ) 生命体征•7.ECOG/PS 体能评分note：后面具体讲解•8. ECG : 12-LEAD ECG 心电图•9. ECHO ( ECHOCARDIOGRAM ) 超声心动图•10. HAEMA ( LOCAL LABORATORY –HAEMATOLOGY )血常规•11. CHEM ( LOCAL LABORATORY –CLINICAL CHEMISTRY )血生化•12. URIN ( urine ) 尿常规•13. C1 ( Cycle1 ) 第一周期•14. WD : End of Therapy/DISCONTINUATION 结束治疗(停止用药)•15. FU ( Follow-up ) 随访•16.CMED( CONCOMITANT MEDICATIONS ) 伴随药物•17. AE ( NON-SERIOUS ADVERSE EVENTS ) 不良事件•18. SAE ( SERIOUS ADVERSE EVENTS ) 严重不良事件•19. EOS( End of Study ) 结束研究：肿瘤以病人死亡事件为准•20. UNS ( Unscheduled Visit ) 不预期访问•21.ND (Not Done) 未做•22. NA (Not Applicable) 不适用• (Unknown) 未知临床试验常见语句描述一. 临床试验过程描述1）一般描述：1. Subject was diagnosed with XX in September, 2010, and had XX surgery in December, 2010.患者于2010 年9 月确诊XX 疾病，于2010 年12 月行XX 术。
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。
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.。
常见医学病案记录术语的中英对照
常见医学病案记录术语的中英对照病案记录术语的中英对照一、主诉 (Chief Complaint)主诉是指患者在就诊时主动告诉医生的症状或原因。
病案记录中通常以简洁的语言来描述患者最主要的不适或问题。
二、现病史 (Present Illness History)现病史是指患者目前所出现的症状、体征，以及这些症状、体征出现的时间、持续时间、频率、程度等详细情况的陈述。
通过现病史可以了解患者当前的健康状况。
三、既往史 (Past Medical History)既往史是指患者在当前就诊之前的生活史、病史、手术史、外伤史、过敏史等。
这些信息对于医生进行诊断、治疗和了解患者的健康状况至关重要。
四、过敏史 (Allergic History)过敏史是指患者对于某些药物、食物或其他物质出现过过敏反应的历史记录。
了解患者的过敏史可以有效避免使用会引起过敏反应的药物或接触过敏原。
五、家族史 (Family History)家族史是指患者的近亲属中是否有某些疾病的遗传倾向或者常见的遗传病史。
通过了解家族史可以评估患者的遗传风险，对医生的诊断和治疗方案的制定有重要影响。
六、体格检查 (Physical Examination)体格检查是指医生通过观察、触摸、听诊、叩诊等方式对患者进行全面的身体检查，以获得有关患者身体状况的客观数据。
七、辅助检查 (Auxiliary Examination)辅助检查是指医生为了进一步了解患者的病情和辅助诊断而进行的各种检查。
常见的辅助检查包括血常规、尿常规、心电图、超声检查等。
八、诊断 (Diagnosis)诊断是指医生根据收集到的病史、体格检查和辅助检查结果，对患者的疾病进行判断和确定。
在病案记录中会根据病情和病理进行具体的诊断说明。
九、治疗方案 (Treatment Plan)治疗方案是指医生根据诊断结果制定的针对患者疾病的治疗计划。
该计划会包括药物治疗、手术治疗、康复计划等。
十、进展观察 (Progress Observation)进展观察主要是记录患者治疗过程中的变化和效果。
病历书写英文单词
病历书写英文单词现病史[History of present illness (HPI/PI)]现病史书写的重点包括：一、主诉中症状的详细描述；二、疾病的发展过程；三、诊疗经过；四、目前的一般情况。
1、诱因·无诱因下[With no inducing factors]·无明显诱因下[Under no obvious predisposing causes]·感冒一周后[After getting (catching) common cold for 1 week] 2、症状出现的叙述·有……症状▲suffer from▲have an attack of▲have(fell)▲begin to fell▲a feeling (sensation) of……▲complain (of)▲……sensation (feeling) in (of) ……▲[发热]have a temperature (become feverish)·在……情况下发生▲活动时呼吸困难[dyspnea on exertion]▲躺下后即出现咳嗽[Cough occurs soon after lying]·与……有（无）关▲与……有关[be associated with]▲与……有关[have (make) relation to]▲与……无关[have (make)no relation to]·在……情况下加重（减轻）▲餐后加重[become worse after taking meals]▲站立后缓解[be relieved by standing up]▲随呼吸和咳嗽而加重[become more severe with breathing and cough] ·伴有……▲be accompanied by3、起病方式·急性腹痛[acute abdominal pain]·慢性低热[chronic lower fever]·暴发性发病[the onset was fulminating]·骤起胸痛[an explosive onset of chest pain]·突然起病伴高热[the onset was sudden with high fever]·突发突止[attacks began and ended abruptly]·因……而突然起病[the attack is precipitated by……]·很快发生晕厥[syncope occured rapidly]·逐渐出现咳嗽咳痰[gradual onset of cough and sputum]·偶而[occasionally (sporadically, accidentally)]·反复胸闷心悸[recurrent (bouts of) chest discomfort and palpitation] ·一过性发作[transitory attack]·连续胸痛[chest pain continually]·时重时轻[waned and waxed]·时好时坏[hang in the balance]·不停地咳嗽[have a fit of cough]·发作性呼吸困难[paroxysmal short of breath]·频繁咳嗽[cough frequently (very often)]·持续性（间歇性）[persistent (intermittent)]·频发胸痛[frequent episodes of chest pain]·持续不变[be steady]4、病情变化描述·[症状好转] ▲fell better than before▲take a favorable turn▲take a turn for the better ▲improve▲make favorable progress ▲turn for the better▲change for the better▲be better·[症状减轻] ▲alleviate▲reduce▲palliate▲diminish▲ease(lighten)▲mitigate·[症状消失] ▲disappear▲subside▲regress▲clear up▲vanish▲dissolve▲die (fade) away ▲relieve·[症状加重] ▲be (make,become,get) worse▲worsen▲become more severe▲take a turn for the worse▲be aggravated▲increase in severity▲take a bad turn▲make (become) more serious▲make (become) heavier·[无变化] ▲remain the same as……▲continue without change▲be identical▲be alike▲be similar▲resemble·[时好时坏] ▲wane and wax▲hang in the balance·[体温/血压升降]▲升至[rise (go up) to ]▲已升至[have risen (gone up) to ]▲从……升至……[go up from ……to……]▲升至[be elevated to]▲迅速下降[fall (decline, abate) abruptly]▲骤降（升）[sudden drop (elevation)]▲渐降（升）[fall (elevate) gradually]▲缓慢下降[slow crisis (lysis) of ]▲一天天下降[be (become) lower day by day]▲开始降低[begin to remit]▲降至正常[drop (was reduced) to normal]▲已降至[have gone down (dropped) to]▲回复到正常[return (revert) to normal]▲由……降（升）至……[fall (elev ate) from……to……]▲维持在……水平[maintain at a level of……]▲稳定在……[stabilize at……]▲热退了[fever disappeared]▲不超过[do not go up over (exceed)……]▲在……和……之间波动[fluctuate (vary) between……and……]▲在……至……范围内[range from……to……]▲平均38.5℃[an average temperature of 38.5℃]▲有39.2℃的体温[have fever (a temperature) of 39.2℃]5、症状的时间表示·持续▲lasted for 2 days▲have gone on for 1 month▲have continued for 10 hours▲lasted on the average 3-5 hours▲lasted a variable time from 5 minutes to several hours ▲lasted about half an hour·超过（不到）[move than (less than)]·……以前[two years ago]·多在……时发生[usually between 3 and 5 PM]·未发作过[be free of onsets (attacks) for 2 weeks]6、症状的严重程度·轻度[mild (slight)]·中度[moderate]·重度[severe (serious)]7、症状的其他描述方法·[部位] ▲be located (situated) in (over)[位于] ▲There is localized pain in……[疼痛位于]▲near……[在……附近]▲be localized to (in, over)[局限于]▲be limited (confined) to[局限于]·[表示部位的介词]▲心尖部，表示小的部位或点[at the apex]▲上腹部，表示大的部位[in the upper abdomen]▲在左下肢，表示皮肤表面上（下）的病变[on (beneath) the left lower limb]▲在右肺，表示正上方的相应体表部位[over the right lung]▲嘴上（下）方，表示高低或上下的位置关系[above (below)the mouth]▲左乳皮下[under the skin of the left breast]·[转移/放射]▲转移到……[shift (migrate) to……]▲放射到……[radiate (travel,go,refer)to……]▲从……放射到……[radiate from……to……]·[耳鼻咽喉及口腔症状]▲耳痛[otalgia (pain of ears)]▲耳鸣[tinnitus (ears ring)]▲耳鸣[a buzzing (ringing,singing) in the ears]▲左耳有耳鸣感[a buzzing sensation in the left ear]▲耳聋[deafness (loss in hearing)]▲左耳聋[be deaf of the left ear]▲耳流脓[otorrhea (otopyorrhea)]▲耳出血[otorrhagia]▲耳垢[cerumen (earwax)]▲耳血肿[othematoma]▲鼻塞[nasal obstruction]▲不能用鼻呼吸[be unable to breathe through (by) the nose (nasal dyspnea)]▲打喷涕和流涕[sneezing and nasal discharge]▲水样鼻涕[watery rhinorrhea]▲鼻出血[nosebleed]▲咽喉痛[sore throat]▲口吃[stuttering]▲口臭[ozostomia (saburra,halitosis)]▲张口困难[difficult (inability) to open the mouth]▲张口（吞咽、嚼）困难[difficult in opening the mouth (swallowing，masticating)]▲咽下困难[dysphagia]▲流涎多[have excessive salvation]·[眼科及牙科症状]▲眼睑浮肿[eyelid edema]▲眼痛[pain in the eyes]▲视边模糊[blurring of vision (blurred vision)]▲过度流泪[excessive tearing (watering)]▲视疲劳[asthenopia (visional tired)]▲视力减退[hypopsia (diminution of vision)]▲视力衰弱[o。
中英对照——常用临床医学词汇
常用临床医学术语diseases 疾病acute diseases 急性病advanced diseases 病沉重期，晚期疾病 chronicdiseases 慢性病 communicable diseases 传染病complicating diseases 并发病organic diseases 器质性病paroxysmal diseases 阵发性病periodical diseases 周期病primary(principal)diseases 原发(主导)病secondary diseases 继发病congenital diseases acquired diseases contagious diseases endemic diseases epidemic diseases functional diseases infectious diseases inherited diseases malignant diseasesnutritional diseasesoccupation diseases先天性疾病后天性疾病接触性传染病地方病 流行病机能病、官能病传染病 遗传病恶性病 营养病职业病sexual(venereal, social)diseases 性病terminal diseases 绝症wasting diseases 消耗性疾病chief complaint clinical manifestation 临床表现主诉delivery history 分娩史etiology 病因学familyhistory 家族史history, medical history 病史precipitating(induced) 诱因marital status 婚姻状况menstrual history 月经史menarche 初潮menopause 闭经past history 既往史pathogenesis 发病机制personal history 个人史symptoms 症状cardinal symptom 主要症状classical symptom 典型症状concomitantsymptom 伴发症状constitutional(systemic)symptom 全身症状indirect symptom 间接症状induced symptom 诱发症状local symptom 局部症状mental symptom 精神症状symptom-complex (syndrome)symptom 综合症，症候群signs 体征antecedent 前驱征assident (accessory) 副征commemorative 后遗症sign of death 死征diagnostic 诊断征sign of disease 病征subjective 自觉征，主观征vein sign 静脉征vitalsign 生命体征body length (height of the body)身高body weight 体重barrel chest 桶状胸cachexia 恶病质compulsive position 被动体位critical facies 病危面容emaciation 消瘦enophthalmos 眼球下陷entropion 睑内翻exophthalmos 眼球突出flushed face 面色潮红gain (loss) in weight 增加(减轻)体重lock-jaw 牙关紧闭lordosis 脊柱前凸nasal ala flap 鼻翼扇动nystagmus 眼震obesity 肥胖pallor 苍白scolisis 脊柱侧凸agitation 焦急不安debility, weakness 虚弱diaphoresis 出汗，大量出汗dizziness, vertigo 眩晕lassitude, fatigue 无力，倦怠malaise 不适night sweat 盗汗numbness 麻木rigor, chill 寒冷，发冷perspiration, sweating 出汗pruritus, itching 痒，somasthenia 躯体无力tingling 麻刺感abscess 脓肿acidosis 酸中毒adhesion 粘连alkalosis 碱中毒allergy 过敏coagulation defect 凝血不良congestion 充血dehydration 脱水distention 膨胀 edema 水肿 embolism 栓塞，栓塞形成 fluid and electrolyte imbalance gangrene 坏疽 hematoma 血肿 hemorrhage, bleeding 出血 infarction 梗塞，梗死 infection 传染 inflammation 炎症 ketoacidosis 酮酸中毒 metastasis 转移 perforation 穿孔 necrosis 坏死 shock 休克 response 反应，应答 reaction 反应，感应 thrombosis血栓形成 ulceration 溃疡 fever,pyrexia continuous fever 稽留热intermittent fever 间歇热 low-gradefever 低热remittent fever 驰张热relapsing fever 回归热 pain 痛burning pain 灼痛chest(flank, …)pain 胸(胁腹…)痛cramp-like pain 痉挛性痛dull, diffused pain 弥漫性钝痛pleuritic pain 胸膜炎性痛radiating pain (pain radiating to放…射) 性痛(放射到 … 疼痛) angina 绞痛 cardiac angina 心绞痛backache 背痛colic 绞痛，急腹痛earache 耳痛水电解质紊乱发烧，发热neuralgia 神经痛migraine 偏头痛rebound tenderness 反跳痛somatalgia 躯体痛sore throat 咽喉痛stomachache 胃痛toothache 牙痛bloody sputum 带血的痰cough 咳嗽dry cough 干咳expectoration 咳痰expectoration of blood 咳血hemoptysis 咳血anoxia 缺氧apnea 呼吸暂停，窒息asthma 气喘，哮喘Cheyne Stokes respiration 切－斯氏呼吸，潮式呼吸dyspnea 呼吸困难hyperpnea hyperventilation 过度呼吸，换气过度hypopnea 呼吸不全，呼吸浅表hypoxia 低氧，缺氧orthopnea 端坐呼吸respiratory arrest 呼吸停止suffocation 窒息tachypnea 呼吸急促fruity breath 呼吸有水果味arrhythmia 心律失常，心律不齐atelectasis 肺不张，肺膨胀不全cardiac arrest 心搏骤停cardiac hypertrophy 心脏肥大cyanosis 发绀，青紫distension of jugular vein 颈静脉怒张extrasystole 期外收缩gallop rhythm 奔马律hemopleura 血胸hepatojugular reflux 肝颈静脉回流hypovolemia （循环）血容量减少palpitation 心悸tachycardia 心动过速pneumothorax 气胸thrill 震颤absent breath sounds 呼吸音消失dull sound 浊音hyperresonant 鼓音rale 啰音rhonchus, rhonchi 鼾音，干啰音wheeze 哮鸣音anorexia, loss of appetite 食欲不振，厌食dysphagia 吞咽困难eructation 嗳气belching 嗳气flatus 肠胃气，屁gaseous distention 胃胀气hematemesis 呕血hiccough, hiccup 打呃，呃逆nausea 恶心pyrosis 胃灼热regurgitation 反胃，回流thirsty 口渴vomiting 呕吐anal fissure, crack in the anal canal 肛裂board-like rigidity of the abdomen 板状腹decreased tactile fremitus 触觉性震颤减弱exophageal varices 食管静脉曲张fistula 瘘，瘘管hemorrhoid 痔hernia 疝hepatomegaly 肝肿大intussusception 肠套叠jaundice 黄疸muscle guarding, defence of the abdominal wall peristalsis 蠕动loss of peristalsis 蠕动消失mass peristalsis 总蠕动retrograde (reversed) peristalsis 逆蠕动prolapse 脱垂prolapse of anus 脱肛rectal prolapse 直肠脱垂，脱肛volvulus 肠扭转calculus 结石，石biliary calculus 胆结石vesical calculus 膀胱结石constipation 便秘defecation 排便diarrhea 腹泻incontinence of feces 大便失禁hematochezia 便血fecal impaction 大便嵌塞腹壁肌卫occult blood 潜血painful straining with defecation 排便痛性牵动clay colored stools 陶土色便dark, granular/coffee ground emesis 咖啡样呕吐物fecal vomiting, stercoraceous vomiting呕粪，吐粪foul fatty stools, steatorrhea 恶臭脂肪便，脂肪痢scanty and hard stools 便少而硬tarry (black) stools 柏油样便anuria 无尿burning sensation no urination 排尿时的灼烧感dysurea 排尿困难，尿痛enuresis, bed wetting 遗尿frequency of urination 尿频micturation 排尿uresis, urination, voiding 排尿nocturia 夜尿oliguria 少尿polyuria 多尿tenesmus 里急后重vesical tenesmus 排尿时里急后重uremia coma 尿毒症昏迷urgency of urination 尿急urinary incontinence 尿失禁aciduria 酸尿chyluria 乳糜尿cylindruia 管型尿glycosuria 糖尿hematuria 血尿ketonuria 酮尿pneumatinuria 气尿proteinuria 蛋白尿pyuria 脓尿amenorrhea 经闭，无月经dysmenorrhea 痛经menorrhagia 月经过多lochia 恶露menorrhea 行经，月经过多menstruation 月经uterine contraction 子宫收缩blotch 斑点bruise 挫伤，青肿acne 痤疮，粉刺desquamation 脱皮，脱屑ecchymosis 瘀斑loss of skin turgor 失去皮肤充盈nevus 痣papule 丘疹petechia 瘀点，瘀斑pigmentation 色素沉着pustule 脓疱purpura 紫癫red nodule 红结节roseola 玫瑰疹scar 伤疤senile plaque 老人斑spider anaioma 蛛形痣subcutaneous nodule 皮下结节urticaria 荨麻疹vesicle 小水疱vitiligo 白斑blindness 失明blurred vision, visual disturbance 视力模糊impaired vision 视力下降lacrimation 流泪papilledema 视神经乳头水肿photophobia 畏光，羞明retinal detachment 视网膜脱离deafness 聋hearing loss 听力丧失tinnitus 耳鸣epistaxis, nasal bleeding 鼻出血impaired smelling 嗅觉障碍nasal discharge 鼻涕nasal obstruction 鼻塞sneeze 喷嚏snore 打鼾aphonia, loss of voice 失音症hoarseness 嘶哑gum bleeding 齿龈出血herpes labialis 唇疱疹，感冒疮Koplik's spots 科普利克斑lead line of the gum 龈铅线salivation, drooling 流口水straw-berry tongue 草莓舌tremulous tongue 舌震颤atrophy 萎缩contracture 挛缩deformity 畸形，变形dislocation 脱位fracture 骨折closed （simple）fracture 无创骨折，单纯性骨折comminuted fracture 粉碎性骨折compound fracture 哆开（开放性）骨折knock-knee 膝外翻opisthotonos 角弓反张prosthesis 假体spasm 痉挛tetany （肌）强直，手足抽搦wrist drop 腕下垂aphasia 失语ataxia 共济失调coma 昏迷consciousness 知觉，意识convulsion 抽搐，惊厥delirium 谵妄delusion 妄想faint 昏厥hallucination 幻觉hemiplegia 偏瘫increased intracranial pressure 颅内压增高insanity 精神错乱loss of orientation 定向丧失mania 躁狂memory defects, amnesia 记忆缺损，遗忘症paraplegia 截瘫，下身麻痹projectile vomiting 喷射性呕吐somnolence, (lethargy) 昏睡，嗜睡stupor 木僵，昏呆tetraplegia 四肢瘫痪unconsciousness 失去知觉yawning 打哈欠crisis 危象cerebral (febrile, hematic, hemolytic,hypertensive, thyrotoxic, ..... ) crisis 脑(热、血性、溶血、高血压、甲状腺中毒…)危象failure 衰竭，故障central (circulatory, cardiac, myocardiac, peripheral, congestive, renal, respiratory) failure 中枢（循环、心力、心肌、周围循环、充血性、肾、呼吸…）衰竭diagnosis诊断auscultation 听诊inspection 视诊palpation 触诊percussion 叩诊laboratory examination 实验室检查physical examination 体格检查rectal (vaginal) touch 直肠（阴道）指诊impression 印象tentative diagnosis 暂定诊断differential diagnosis 鉴别诊断final diagnosis 最后诊断prognosis 预后prescription 处方incubation (latent) period 潜伏期prodromal stage 前驱期incipient stage 初期quiescent stage 静止期alleviation 减轻，缓和remission 缓解attack 发作convalescence (recovery) stage 恢复期rehabilitation 康复relapse 复发sudden death 猝死moribund 濒死的course of the disease 病程course of the treatment 疗程indication 适应症，指征complication 并发症contraindication 禁忌症side-effect 副作用sequel (sequela), after effect 后遗症therapies 治疗方法acupuncture therapy 针刺疗法block therapy 封闭疗法chemical therpy (chemo-therapy) 化学疗法combined therapy 综合疗法conservative therapy 保守疗法constitutional therapy 全身疗法dietetic therapy 饮食疗法operative treatment 手术疗法palliative treatment, alleviative treatment 姑息疗法physical therapy 物理疗法psychotherapy 精神疗法radical treatment 根治radio-therapy 放射性疗法supporting treatment 支持疗法symptomatic treatment 对症疗法cardiac massage 心脏按摩cardiac pacing 心脏起博electrotherapy 电疗法electroshock treatment 电休克疗法hemodialysis 血液透析hyperbaric therapy 高压氧疗法insulin-shock treatment 胰岛素休克疗法light therapy 光疗法therapeutic gymnastics 医疗体育。
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。