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, you

should 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

chest 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 dysuria

hematuria 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：