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语际翻译公司 转载请注明https://www.scientrans.com
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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
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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