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您現(xiàn)在的位置: 醫(yī)學(xué)全在線 > 醫(yī)學(xué)英語 > 英語教學(xué) > 英文病歷 > 正文:簡明病歷書寫手冊第四章:過去史、系統(tǒng)回顧和個人史
    

簡明病歷書寫手冊第四章:過去史、系統(tǒng)回顧和個人史

(Past history, systems review and personal history)
1、過去史[past history]
•無藥物(食物)過敏史[no past history of allergy to drugs (food )]
•有青霉素過敏史[have allergic history of pencillin]
•有肺結(jié)核接觸史[there was contact histoy of lung tuberculosis]
•2000年6月因急性闌尾切除術(shù)[Appendectomy was done in June, 2000 due to acute appendicitis]
•健康狀況佳(差)[health state was good (bad)]
•既往體健[be well (healthy) before]
•否認(rèn)既往心、肺疾病史[deny any history of prior heart and lung disease]
•10歲時(20年前)曾患過……[suffered from…… at age 10(20 years ago)]
•易患……[be liable (subjuct, apt) to……]
•不詳[not in detail (not quite clear)]
•外傷史[rtauma history]
•預(yù)防接種史[history of preventive inoculation]
2、系統(tǒng)回顧[system review]
•呼吸系統(tǒng):咳嗽、咳痰、呼吸困難、胸痛、盜汗發(fā)熱[respiratory system: cough, sputum, short of breath, chest pain, night sweeting, fever.]醫(yī)學(xué)全.在線.網(wǎng).站.提供
•循環(huán)系統(tǒng):心悸、胸痛、氣促、咳嗽和咯血、水腫、暈厥、頭暈[Circulatory system: palpitation, chest pain, short of breath, cough and hemoptysis, edema, syncope, dizziness.]
•消化系統(tǒng):噯氣、返酸、腹脹、腹痛、腹瀉、惡心和嘔吐[alimentary system: belching, sour regurgitation, abdominal distension, abd. pain, diarrhea, nausea and vomiting.]
•泌尿系統(tǒng):排尿困難、尿頻和尿急、尿痛、腹痛、水腫[urinary system: difficulty in micturition, frequency and rugency of micturition, painful micturition, abdominal pain, edema.]
•造血系統(tǒng):乏力、頭暈、心悸、出血[hematopoietic system:fatigue, dizziness, palpitation, bleeding.]
•內(nèi)分泌系統(tǒng):心悸、怕熱、多汗、煩渴、水腫、手抖、消瘦和肥胖[endocrine system: palpitation, heat intolerance, excessive sweeting, polydipsia, edema, hand tremble, wasting and obesity.]
•神經(jīng)系統(tǒng):頭痛、暈厥、頭暈和眩暈、失眠、偏癱、失語[nervous system: headache, coma, dizziness and vertigo, insomnia, hemiplegia, aphasia.]醫(yī)學(xué).全在.線www.med126.com
•運動系統(tǒng):關(guān)節(jié)痛、麻木、跛行、癱瘓[motor system: joint pain, numbness, claudication, paralysis.]
3、個人史[personal history]
•出生于(出生地)[was born in (birthplace)]
•出生后一直生活[have lived in……(there) since birth]
•曾(未曾)去過北方[have (deny having) been to the north]
•受教育程度(文、小學(xué)、中學(xué)、大學(xué))[educational level (illiterate, primary, middle, high grade)]
•業(yè)余愛好[hobby (be fond of, be keen of, interest)]
•從事……職業(yè)[be engaged in]
•衛(wèi)生習(xí)慣和嗜好[health habit and special addiction]
•不潔性交(性行為)史[history of unclean coitus (sexual behavior)]
    •不吸煙[ no smoking(not a smoker)]
•吸煙20年,每天2包[have smoked two packages of cigarette a day for 20 years]
•戒煙[give up (stop) smoking]
•戒煙[smoking abstinence (withdrawal)]
•不飲酒[no alcohol use]
•偶而少量飲酒[drink little liquor occasionally]
•過度飲酒[drink heavily (too much)]
•每天飲酒0.5公斤[drink (imbibe) about 0.5 kilogram a day]
•酒精性飲料[alcoholic beverage]
•偏食[food preference (particular with food)]
•無偏食[no likes or dislikes in food]
•偏愛……[have partiality for (showe favoritism to, be partial to, like)]
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