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    简明病历书写手册第四章:过去史、系统回顾和个人史

       作者:古龙   2009-07-04
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            (Past history, systems review and personal history)
           1、过去史[past history]
           •无药物(食物)过敏史[no past history of allergy to drugs (food )]
           •有青霉素过敏史[have allergic history of pencillin]
           •有肺结核接触史[there was contact histoy of lung tuberculosis]
           •2000年6月因急性阑尾切除术[Appendectomy was done in June, 2000 due to acute appendicitis]
           •健康状况佳(差)[health state was good (bad)]
           •既往体健[be well (healthy) before]
           •否认既往心、肺疾病史[deny any history of prior heart and lung disease]
           •10岁时(20年前)曾患过……[suffered from…… at age 10(20 years ago)]
           •易患……[be liable (subjuct, apt) to……]
           •不详[not in detail (not quite clear)]
           •外伤史[rtauma history]
           •预防接种史[history of preventive inoculation]
           2、系统回顾[system review]
           •呼吸系统:咳嗽、咳痰、呼吸困难、胸痛、盗汗、发热[respiratory system: cough, sputum, short of breath, chest pain, night sweeting, fever.]医学全.在线.网.站.提供
           •循环系统:心悸、胸痛、气促、咳嗽和咯血、水肿、晕厥、头晕[Circulatory system: palpitation, chest pain, short of breath, cough and hemoptysis, edema, syncope, dizziness.]
           •消化系统:嗳气、返酸、腹胀、腹痛、腹泻、恶心和呕吐[alimentary system: belching, sour regurgitation, abdominal distension, abd. pain, diarrhea, nausea and vomiting.]
           •泌尿系统:排尿困难、尿频和尿急、尿痛、腹痛、水肿[urinary system: difficulty in micturition, frequency and rugency of micturition, painful micturition, abdominal pain, edema.]
           •造血系统:乏力、头晕、心悸、出血[hematopoietic system:fatigue, dizziness, palpitation, bleeding.]
           •内分泌系统:心悸、怕热、多汗、烦渴、水肿、手抖、消瘦和肥胖[endocrine system: palpitation, heat intolerance, excessive sweeting, polydipsia, edema, hand tremble, wasting and obesity.]
           •神经系统:头痛、晕厥、头晕和眩晕、失眠、偏瘫、失语[nervous system: headache, coma, dizziness and vertigo, insomnia, hemiplegia, aphasia.]
           •运动系统:关节痛、麻木、跛行、瘫痪[motor system: joint pain, numbness, claudication, paralysis.]
           3、个人史[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)去过北方[have (deny having) been to the north]
           •受教育程度(文盲、小学、中学、大学)[educational level (illiterate, primary, middle, high grade)]
           •业余爱好[hobby (be fond of, be keen of, interest)]
           •从事……职业[be engaged in]
           •卫生习惯和嗜好[health habit and special addiction]
           •不洁性交(性行为)史[history of unclean coitus (sexual behavior)]
               •不吸烟[ no smoking(not a smoker)]
           •吸烟20年,每天2包[have smoked two packages of cigarette a day for 20 years]
           •戒烟[give up (stop) smoking]
           •戒烟[smoking abstinence (withdrawal)]
           •不饮酒[no alcohol use]
           •偶而少量饮酒[drink little liquor occasionally]
           •过度饮酒[drink heavily (too much)]
           •每天饮酒0.5公斤[drink (imbibe) about 0.5 kilogram a day]
           •酒精性饮料[alcoholic beverage]
           •偏食[food preference (particular with food)]
           •无偏食[no likes or dislikes in food]
           •偏爱……[have partiality for (showe favoritism to, be partial to, like)]
           来源:医学全在线

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