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病历中中英文对照
第一章 病人身份[Identification]
• [Name] 姓名
• [Sex] 性别• [Age] 年龄• [Occupation] 职业• [Date of birth] 出生日期• [Marriage (Marital status)] 婚姻• [Race] 民族• [Place of birth (Birth place)] 籍贯• [Identification No.(code of ID card No.)] 身份证号码• [Department of work and TEL. No. (Unit and Business phone No.)] 工作单位及电话• [Home address and phone No.] 家庭住址及电话• [Post code] 邮政编码• [Person to notify (Correspondent) and phone No.] 联系人及电话• [Source (Complainer;offerer;supplier;provider) of history] 病史陈术者• [Reliability of history] 病史可靠程试• [Medical security (Type of payment)] 医疗费用• [Type of admission (Patient condition)] 住院类别(入院时病情)• [Medical record No.] 病历号• [Clinic diagnosis] 门诊诊断
• [Date of admission (admission date)] 入院日期 [Date of record] 记录日期
1、年龄的表示方法(以36岁为例)
•36 years old (y/o)•Age 36•36 year-old•The age of 36
•36 years of age
2、性别的表示方法
• [Male,♂] 男性• [Female,♀] 女性
3、职业的表示方法
•工人[Worker] •退休工作[Retired worker]•农民[Farmer (peasant)] •干部[Leader (cadre)]•行政人员[administrative personnel (staff)]•职员[staff member] •商人[Trader (Businessman)]•教师[Teacher] •学生[Student] •医生[Doctor]•药剂师[Pharmacist]•护士[Nurse] •军人[Soldier] •警察[Policeman]•工程师[Engineer] •技术员[Technician] •家政人员[Housekeeper]•家庭主妇[Housewife] •营业员[Assistant] •服务员[Attendant]•售票员[Conductor]
4、民族的表示方法
•汉[Han] •回[Hui] •蒙[Meng] •藏[Tibetan]•朝鲜[Korean]•美国人[American] •日本人[Japanese] •英国人[Britisher]
5、医疗费用的表示方法
• [Self pay (Individual medical care)] 自费• [Government insruance (Public medical care)] 公费• [Insurance] 保险
• [Local insurance] 本地医保• [Non-local in surance] 外地医保• [Labor protestion care] 劳保
6、婚姻状况的表示方法
• [Married] 已婚 • [Single (Unmarried)] 未婚 • [Diverced] 离婚• [Widow] 寡妇 • [Widower] 鳏夫
7、病史可靠程度的表示方法
• [Reliable] 可靠
• [Unreliable] 不可靠
• [Not entirely] 不完全可靠
• [Unobtainable] 无法获得
8、住址的表示方法
•[NO.3,Qing Chun Road East,Hangzhou, Zhejiang] 浙江省杭州市庆春东路3号
•[XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.] 浙江省诸暨市(县)城关镇新东村
9、病史陈述者的表示方法
• [Patient himself (herself)] 患者本人• [Her husband] 患者的丈夫• [His wife] 患者的妻子• [Patient`s colleague] 患者的同事
• [Patient`s neighbor] 患者的邻居• [Patient`s Kin (Mother; Son; daughter;brother;Sister)] 患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹)• [Taximan] 出租车司机• [Traffic police] 交通警察
10、日期的表示方法
•2002年10月1日[10-1-2002(10/1/2002; Oct.1,2002; Oct.lst,2002)](美国)
•2002年10月1日[1-10-2002(1/10/2002; 1 Oct.,2002; 1st of Oct.,2002)] (英国)
11、住院类别的表示方法
• [Emergent (Emergency call)] 急诊• [Urgent] 危重• [Elective (General)] 一般(普通)
12、入院时病情的表示方法
• [Stable] 稳定 • [Unstable] 不稳定• [Relative stable] 相对稳定• [Critical (Imminent)] 危重• [Fair (General)] 一般
第二章 主诉[Chief Complaint]
1、主诉的表示方法:症状+时间(Symptom+Time)
•症状+for+时间
如: [Chest pain for 2 hours] 胸痛2小时
•症状+of+时间
如: [Nausea and vomiting of three days` duration] 恶心呕吐3天
•症状+时间+in duration
如: [Headache 1 month in duration] 头痛1月
•时间+of+症状
如: [Two-day history of fever] 发热2天
2、常见症状
• [Fever] 发热
• [Pain] 疼痛
• [Edema] 水肿
• [Mucocutaneous hemorrhage (bleeding)] 皮肤粘膜出血
• [Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困难
• [Cough and expectoration (Sputumhlegm)] 咳嗽和咯痰
• [Hemoptysis] 咯血
• [Cyanosis] 紫绀
• [Palpitation] 心悸
• [Chest discomfort] 胸闷
• [Nausea (Retch;Dry Vomiting)and Vomiting] 恶心和呕吐
• [Hematemesis (Vomiting of blood)] 呕血
• [Hematochezia (Hemafecia)] 便血
• [Diarrhea] 腹泻
• [Constipation (Obstipation)] 便秘
• [Vertigo (Giddiness; Dizziness)] 眩晕
• [Jaundice (Icterus)] 黄疸
• [Convulsion] 惊厥
• [Disturbance of consciousness] 意识障碍
• [Hematuria] 血尿
• [Frequent micturition,urgent micturition and dysuria] 尿频,尿急和尿痛
• [Incontinence of urine] 尿失禁
• [Retention of urine] 尿潴留
(1)发热的表示方法
• [Infective (Septic)fever] 感染性发热
• [Non-infective (Aseptic)fever] 非感染性发热
• [Dehydration (Inanition)fever] 脱水热
• [Drug fever] 药物热
• [Functional hypothermia] 功能性低热
• [Absorption fever] 吸收热
• [Central fever] 中枢性发热
• [Fever type] 热型
▲ [Continuous fever] 稽留热
▲ [Remittent fever] 驰张热
▲ [Intermittent fever] 间歇热
▲ [Undulant fever] 波状热
▲ [Recurrent fever] 回归热
▲ [Periodic fever] 周期热
▲ [Irregular fever] 不规则热
▲ [Ephemeral fever] 短暂热
▲ [Double peaked fever] 双峰热
• [Fever of undetermined(unknown) origin, FUO] 不明原因发热
• [Rigor (shivering;chill;shaking chill;ague)] 寒战
• [Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒
• [Ultra-hyperpyrexia] 超高热
• [Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高热
• [Moderate fever] 中度发热
• [Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低热
• [Become feverish (Have a temperature)] 发热
• [Crisis] 骤降
• [Lysis] 渐降
• [Typhoid fever] 伤寒热
• [Rheumatic fever] 风湿热
• [Cancerous fever] 癌性发热
• [Fervescence period] 升热期
• [Defervescence period] 退热期
• [Persistent febrile period] 持续发热期
(2)疼痛的表示方法
• [Backache (Back pain)] 背痛
• [Lumbago] 腰痛
• [Headache] 头痛
▲ [Vasomotor headache] 血管舒缩性头痛
▲[Post-traumatic headache] 创伤后头痛
▲[Migraine headache] 偏头痛
▲ [Cluster headache] 丛集性头痛
• [Chest pain] 胸痛
• [Precardial pain] 心前区痛
• [Retrosternal pain] 胸骨后痛
• [Abdominal pain (Stomachache)] 腹痛
• [Acrodynia (pain in limbs)] 肢体痛
• [Arthrodynia (Arthralgia)] 关节痛
• [Dull pain] 钝痛
• [Sharp pain] 锐痛
• [Twinge pain] 刺痛
• [Knife-like pain (Piercing pain)] 刀割(刺)样痛
• [Aching pain] 酸痛
• [Burning pain] 烧灼痛
• [Colicky (Griping;cramp) pain] 绞痛
• [Colic] 绞痛
• [Bursting pain] 胀痛(撕裂痛)
• [Hunger pain] 饥饿痛
• [Tic pain] 抽搐痛
• [Bearing-down pain] 坠痛
• [Shock-like pain] 电击样痛
• [Jumping pain] 反跳痛
• [Tenderness pain] 触痛(压痛)
• [Girdle-like pain] 束带样痛
• [Wandering pain] 游走性痛
• [Throbbing pain] 搏动性痛
• [Radiating pain] 放射性痛
• [Cramping pain] 痉挛性痛
• [Boring pain] 钻痛
• [Intense pain] 剧痛
• [Writhing pain] 痛得打滚
• [Dragging pain] 牵引痛
• [Labor pain] 阵痛
• [Cancerous pain] 癌性疼痛
• [Referred pain] 牵涉痛
• [Persistent pain (Unremitting pain)] 持续性痛
• [Constant pain] 经常性痛
• [Intermittent pain] 间歇性痛
(3)水肿的表示方法
• [Mucous edema (Myxedema)] 粘液性水肿
• [Cardiac (Cardiogenic) edema] 心源性水肿
• [Nephrotic (renal) edema] 肾源性水肿
• [Hepatic edema] 肝源性水肿
• [Alimentary (Nutritional) edema] 营养不良性水肿
• [Angioneurotic edema] 血管神经性水肿
• [Pitting] 凹陷性
• [Nonpitting] 非凹陷性
• [Localized (Local) edema] 局限性水肿
• [Generalized edema (Anasarca)] 全身性水肿
• [Hydrops] 积水
• [Elephantiasic crus] 橡皮肿
• [Cerebral(Brain) edema] 脑水肿
• [Pulmonary edema (Hydropneumonia0] 肺水肿
• [Hydrocephalus] 脑积水
• [Edema of endoscrinopathy] 内分泌病性水肿
• [Invisible (Recessive) edema] 隐性水肿
• [Frank edema] 显性水肿
• [Inflammatory edema] 炎性水肿
• [Idiopathic edema] 特发性水肿
• [Cyclical edema] 周期性水肿
• [Ascites (Abdominal effusion;hydroperiotoneum)] 腹水
• [Pleural effusion (Hydrothorax)] 胸水
• [Pericardial effusion (Hydropericardium)] 心包积液
• [Bronchoedema] 支气管水肿
• [Slight (Mild)] 轻度
• [Moderate] 中度
• [Serious] 重度
• [Transudate] 漏出液
• [Exudate] 渗出液
(4)呼吸困难的表示方法
• [Cardiac dyspnea] 心原性呼吸困难
• [Inspiratory] 吸气性
• [Expiratory] 呼气性
• [Mixed] 混合性
• [Obstructive] 梗阻性
• [Dyspnea at rest] 静息时呼吸困难
• [Dyspnea on exertion] 活动时呼吸困难
• [Dyspnea on lying down] 躺下时呼吸困难
• [Paroxysmal nocturnal dyspnea,PND] 夜间阵发性呼吸困难
• [Orthopnea] 端坐呼吸
• [Asthma] 哮喘
• [Cardiac asthma] 心源性哮喘
• [Bronchial asthma] 支气管性哮喘
• [Hyperpnea] 呼吸深快
• [Periodic breathing] 周期性呼吸
• [Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)]气促
• [Bradypnea (Slow breathing)] 呼吸缓慢
• [Irregular breathing] 不规则呼吸
(5)皮肤粘膜出血的表示方法
• [Bleeding spots in the skin] 皮肤出血点
• [Petechia] 瘀点
• [Eccymosis] 瘀斑
• [Purpura] 紫癜
• [Splinter hemorrhage] 片状出血
• [Oozing of the blood (Errhysis)] 渗血
• [Blood blister (Hemophysallis)] 血疱
• [Hemorrhinia (Nasal bleeding)] 鼻衄
• [Ecchymoma] 皮下血肿
(6)咳嗽与咯痰的表示方法
• [Dry cough (Nonproductive cough;hacking cough)] 干咳
• [Sharp cough] 剧咳
• [Wet cough (Moist cough)] 湿咳
• [Productive cough (Loose cough)] 排痰性咳
• [Chronic cough] 慢性咳嗽
• [Irritable cough] 刺激性咳嗽
• [Paroxysmal cough] 发作性(阵发性)咳嗽
• [Cough continually] 持续性咳嗽
• [Spasmodic cough] 痉挛性咳嗽
• [Whooping cough] 百日咳
• [Winter cough] 冬季咳
• [Wheezing cough] 喘咳
• [Short cough] 短咳
• [Distressed cough] 难咳
• [Shallow cough] 浅咳
• [Droplet] 飞沫
• [Frothy sputum] 泡沫样痰
• [Bloody sputum] 血痰
• [Mucous (Mucoid) sputum] 粘液样痰
• [Purulent sputum] 脓痰
• [Mucopurulent sputum] 粘液脓性痰
• [White (Yellow,green) sputum] 白(黄,绿)痰
• [Fetid (Foul) sputum] 恶臭痰
• [Iron-rust (Rusty) sputum] 铁锈色痰
• [Chocolate coloured sputum] 巧克力色痰
• [Thick sputum] 浓痰
• [Thin sputum] 淡痰
• [Viscous sputum] 粘痰
• [Transparent sputum] 透明痰
• [Much (Large amounts of) sputum] 大量痰
• [Moderate amounts of sputum] 中等量痰
• [Not much (Small amounts of ) sputum] 少量痰
(7)内脏出血的表示方法
• [Goldstein’s hemoptysis]戈耳斯坦氏咯血
• [Massive hematemesis]大量呕血
• [Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)]鼻衄
• [Hematuria] 血尿
• [Initial hematuria] 初血尿
• [Idiopathic hematuria] 特发性血尿
• [Painless hematuria] 无痛性血尿
• [Terminal hematuria] 终末性血尿
• [Gross (Macroscopic) hematuria] 肉眼血尿
• [Microscopic hematuria] 镜下血尿
• [Hematuria in the whole process of urination] 全程血尿
• [Gingival bleeding (Ulaemorrhagia;gum bleeding)] 牙龈出血
• [Hematochezia] 便血
• [Bloody stool] 血便
• [Black stool (Melena)] 黑便
• [Tarry stool] 柏油样便
• [Bleeding following trauma] 外伤后出血
• [Spontaneous bleeding] 自发性出血
• [Bleeding Continuously] 持续出血
• [Occult blood,OB] 隐血
• [Hematobilia] 胆道出血
• [Hemathorax] 血胸
• [Hemarthrosis] 关节积血
• [Hematocoelia] 腹腔积血
• [Hematoma] 血肿
• [Hemopericardium] 心包积血
• [Cerebral hemorrhage] 脑出血
• [Subarachnoid hemorrhage(SAH)] 蛛网膜下腔出血
• [Excessive (Heavy) menstrual flow with passage of clots] 月经量多伴血块
• [Mild (Moderate) menses] 月经量少(中等)
• [Painless Vaginal bleeding] 无痛性阴道出血
• [Postcoital bleeding] 性交后出血
• [Pulsating bleeding] 搏动性出血
• [Post-operation wound hemorrhage] 术后伤口出血
• [Excessive bleeding after denal extraction] 拔牙后出血过多
(8)紫绀的表示方法
• [Congenital cyanosis] 先天性紫绀
• [Enterogenous] 肠源性
• [Central] 中枢性
• [Peripheral] 周围性
• [Mixed] 混合性
• [Acrocyanosis] 指端紫绀
(9)恶心与呕吐的表示方法
• [Vomiturition (Retching)] 干呕
• [Feel nauseated] 恶心感
• [Postprandial nausea] 饭后恶心
• [Hiccup] 呃逆
• [Sour regurgitation] 返酸
• [Fecal (Stercoraceous) vomiting] 吐粪
• [undigested food Vomiting] 吐不消化食物
• [Bilious Vomiting] 吐胆汁
(10)腹泻与便秘的表示方法
• [Moning diarrhea] 晨泻
• [Watery (Liquid)diarrhea] 水泻
• [Mucous diarrhea] 粘液泻
• [Fatty diarrhea] 脂肪泻
• [Chronic (Acute)] 慢性(急性)
• [Mild diarrhea] 轻度腹泻
• [Intractable (Uncontrolled)diarrhea] 难治性腹泻
• [Protracted diarrhea] 迁延性腹泻
• [Bloody stool] 血梗
• [Frothy stool] 泡沫样便
• [Formless (Formed)stool] 不成形(成形)便
• [Loose (Hard) stool] 稀(硬)便
• [Rice-water stool] 米泔样便
• [Undigested stool] 不消化便
• [Dysenteric diarrhea] 痢疾样腹泻
• [Inflammatory diarrhea] 炎症性腹泻
• [Osmotic] 渗透性
• [Secretory] 分泌性
• [Malabsorption] 吸收不良性
• [Lienteric] 消化不良性
• [Pancreatic diarrhea] 胰性腹泻
• [Tenesmus] 里急后重
• [Pass a stool (Have a passage; open or relax the bowel)] 解大便
• [Have a call of nature] 便意
• [Fecal incontinence (Copracrasia)] 大便失禁
• [Functional constipation] 功能性便秘
• [Organic constipation] 器质性便秘
• [Habitual constipation] 习惯性便秘
• [Have a tendency to be constipated] 便秘倾向
(11)黄疸的表示方法
• [Latent (occult) jaundice] 隐性黄疸
• [Clinical jaundice] 显性黄疸
• [Nuclear icterus] 核黄疸
• [Physiologic icterus] 生理性黄疸
• [Icterus simplex] 传染性黄疸
• [Toxemic icterus] 中毒性黄疸
• [Hemolytic] 溶血性
• [Hepatocellular] 肝细胞性
• [Obstructive] 阻塞性
• [Congenital] 先天性
• [Familial] 家族性
• [Cholestatic] 胆汁淤积性
• [Hematogenous] 血源性
• [Malignant] 恶性
• [Painless] 无痛性
(12)意识障碍的表示方法
• [Somnolence] 嗜睡
• [Confusion] 意识模糊
• [Stupor] 昏睡
• [Coma] 昏迷
• [Delirium] 谵妄
• [Syncope (swoon; faint)] 晕厥
• [Drowsiness] 倦睡
(13)排尿的表示方法
• [Enuresis (Bed-wetting)] 遗尿
• [Anuria] 无尿
• [Emiction interruption] 排尿中断
• [Interruption of urinary stream] 尿线中断
• [Nocturia] 夜尿
• [Oliguria] 少尿
• [Polyuria] 多尿
• [Pass water (Make water; urinate; micturition)] 排尿
• [Frequent micturition (Frequency of micturition; fruquent urination;
Pollakiuria)] 尿频
• [Urgent micturition (Urgency of urination or micturition)] 尿急
• [Urodynia (Pain on micturition; painful micturition; alginuresis; micturition pain)] 尿痛
• [Dysuria (Difficulty in micturition; disturbance of micturition)] 排尿困难
• [Small urinary stream] 尿线细小
• [Void with a good stream] 排尿通畅
• [Guttate emiction (Dribbling following urination;terminal dribbling)] 滴尿
• [Bifurcation of urination] 尿流分叉
• [Residual urine] 残余尿
• [Extravasation of urine] 尿外渗
• [Stress incontinence] 压力性尿失禁
• [Overflow incontinence] 溢出性尿失禁
• [Paradoxical in continence] 反常性尿失禁
3.少见症状
• [Weekness( Debility; asthenia; debilitating)] 虚弱(无力)
• [Fatigue (Tire; lassitude)] 疲乏
• [Discomfort (Indisposition; malaise)] 不适
• [Wasting (thin; underweight; emaciation; lean)] 消瘦
• [Night sweating] 盗汗
• [Sweat (Perspiration)] 出汗
• [Cold sweat] 冷汗
• [Pruritus (Iching)] 搔痒
• [Asthma] 气喘
• [Squeezing (Tightness; choking; pressing) sensation of the chest] 胸部紧缩
(压榨)感
• [Intermittent claudication] 间歇性跛行
• [Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis)] 吞咽困难
• [Epigastric (Upper abdominal) discomfort] 上腹部不适
• [Anorexia (Sitophobia)] 厌食
• [Poor appetite (Loss of appetite)] 纳差
• [Heart-burn( Pyrosis)] 胃灼热
• [Stomachache( Pain in stomach)] 胃部痛
• [Periumbilial pain] 脐周痛
• [Belching (Eructation)] 嗳气
• [Sour regurgitation] 返酸
• [Abdominal distention(bloating)] 腹胀
• [Pass gas( Break wink)] 肛门排气
• [Small(Large) stool] 大便少(多)
• [Expel(Pass) worms] 排虫
• [Pain over the liver] 肝区痛
• [Lumbago] 腰痛
• [Pica(Parorexia; allotriophagy)] 异食癖
• [Dysmenorrhea] 痛经
• [Menoxenia (Irregular menstruation)] 月经不调
• [Polymenorrhea (Epimenorrhea)] 月经过频
• [Oligomenorrhea] 月经过少
• [Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea)] 经量过多
• [Hypomenorrhea (Scantymenstruation)] 经量过少
• [Menopause (Menostasia; menostasis)] 绝经
• [Amenorrhea (Menoschesis)] 闭经
• [Leukorrhagia] 白带过多
• [Asexuality (lack of libido)] 无性欲
• [Hyposexuality] 性欲低下
• [Hypersexuality] 性欲亢进
• [Prospermia (Ejaculatio praecox)] 早泄
• [Impotency (impotence)] 阳萎
• [Nocturnal emission (Spermatorrhea)] 遗精
• [Lack of potency] 无性交能力
• [Hair loss] 脱发
• [Joint pain (Arthralgia; arthrodynia)] 关节痛
• [Polydipsia (Excessive thirst)] 多饮(烦渴)
• [Polyphagia (Excessive appetite; hyperorexia; bulimia)] 多食
• [Cold (Heat) intolerance] 怕冷(热)
• [Dwarfism (Excessive height)] 身材矮小(高大)
• [Excessive sweating] 多汗
• [Hands tremble] 手抖
• [Obesity (Fatty)] 肥胖
• [Agitation (Anxiety;nervous irritability)] 焦虑(忧虑)
• [Mania] 躁狂
• [Hallucination] 幻觉
• [Aphasia (Logopathy)] 失语
• [Amnesia (Poor memorization;memory deterioration)] 记忆力下降
• [Hemianesthesia] 偏身麻木
• [Formication] 蚁走感
• [Tingling] 麻刺感
• [Hyperpathia] 痛觉过敏
• [Hypalgesia] 痛觉减退
• [Illusion] 错觉
• [Hemiplegia] 半身不遂
• [Insomnia (Poor sleepness;sleeplessness)] 失眠
• [Nightmare] 多梦
• [Numbness] 麻木
• [Pain in limbs (Acrodynia)] 肢体痛
• [Limitation of motion] 活动受限
• [Tetany] 手足抽搐
• [Discharge of pus] 流脓
• [Blurred vision(Hazy vision;blurring of vision; dimness of vision)]视物模糊
• [Burning (Dry) sensation] 烧灼(干燥)感
• [Tearing (Dacryorrhea;Lacrimation)] 流泪
• [Double vision (Diplopia)] 复视
• [Strabismus] 斜视
• [Hemianopia] 偏盲
• [Tired eyes (Eyestrain)] 眼疲
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