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1、第一部分病人身份 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 pho
2、ne 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
3、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 age2、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 administra
4、tive 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
5、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
6、? 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 hu
7、sband 患者的丈夫 ? His wife 患者的妻子 ? Patients colleague 患者的同事? Patients neighbor 患者的邻居 ? Patients 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 ) 名师资料总结 - - -精品资料欢迎下载 - - -
8、 - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 1 页，共 21 页 - - - - - - - - - ?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 ? C
9、ritical (Imminent) 危重? Fair (General) 一般第二部分主诉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
10、 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)an
11、d 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
12、 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 非感染性发热名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 2 页，共 21 页 - - - - - - - - - ? Dehydration (Inanition)fever 脱水热? Drug fever 药物热? F
13、unctional 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 undeterm
14、ined(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 temperat
15、ure) 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
16、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) 肢体痛名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 3 页，共 21 页 - - -
17、- - - - - - ? 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
18、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 (Unr
19、emitting 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? Localize
20、d (Local) edema 局限性水肿? Generalized edema (Anasarca) 全身性水肿? Hydrops 积水? Elephantiasic crus 橡皮肿名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 4 页，共 21 页 - - - - - - - - - ? Cerebral(Brain) edema 脑水肿? Pulmonary edema (Hydropneumonia0 肺水肿? Hydrocephalus 脑积水? Edema of end
21、oscrinopathy 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? Slig
22、ht (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? Ortho
23、pnea 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 breat hing;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? Pet
24、echia 瘀点? Eccymosis 瘀斑? Purpura 紫癜? Splinter hemorrhage 片状出血? Oozing of t he blood (Errhysis) 渗血名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 5 页，共 21 页 - - - - - - - - - ? 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
25、法? Dry cough (Nonproductive cough;hacking cough) 干咳? Sharp cough 剧咳? Wet cough (Moist cough) 湿咳? Productive cough (Lo ose 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? Wheezin
26、g 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 col
27、oured 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? Goldsteins hemoptysis戈耳斯坦氏咯血? Massive hematemesis 大量呕血? Epistasis (Nosebleed;Nasal
28、 bleeding; Hemorrhinia;rhinorrhagia)鼻衄? Hematuria 血尿? Initial hematuria 初血尿? Idiopathic hematuria 特发性血尿? Painless hematuria 无痛性血尿名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 6 页，共 21 页 - - - - - - - - - ? Terminal hematuria 终末性血尿? Gross (Macroscopic) hematuria 肉眼血尿
29、? 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? O
30、ccult 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 Vagina
31、l 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? Vomiturit
32、ion (Retching) 干呕? Feel nauseated 恶心感? Postprandial nausea 饭后恶心? Hiccup 呃逆? Sour regurgitatio n 返酸? Fecal (Stercoraceous) vomiting 吐粪? undigested food Vomiting 吐不消化食物? Bilious Vomiting 吐胆汁名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 7 页，共 21 页 - - - - - - - - - （10
33、）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) sto
34、ol 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
35、 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 simple
36、x 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 血源性名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 8 页，共 21 页 - - - - - - - - - ? Malignant 恶性? Painless 无痛性（12）意识障碍的表示方法
37、? 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 interru ption 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; mict
38、urition) 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 mic
39、turition) 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 con
40、tinence 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 (Persp iration) 出汗? Cold sweat 冷汗? Pruritus (Iching) 搔痒? Asthma 气喘? Squeezing (Tig
41、htness; choking; pressing) sensation of the chest 胸部紧缩名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 9 页，共 21 页 - - - - - - - - - （压榨）感? Intermittent claudication 间歇性跛行? Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis) 吞咽困难? Epigastric (Upper ab
42、dominal) 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) s
43、tool 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? H
44、ypomenorrhea (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
45、? 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 (Fatt
46、y) 肥胖? Agitation (Anxiety;nervous irritability) 焦虑（忧虑）名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 10 页，共 21 页 - - - - - - - - - ? 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? Formi
47、cation 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;
48、 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) 眼疲劳? Foreign body sensation 异物感? Lose the sight (Lose of vision) 失明? Diminution of vision 视力减退? Nictition 眨眼? Ophthalmodyn
49、ia (Eye -ache;ocular pain) 眼痛? Photophobia 畏光? Spots before the eye s 眼前黑点? Deafness(Anacusia) 耳聋? Auditory dysesthesia 听力减退? Otalgia (Otodynia;pain in the ear ;ear-ache) 耳痛? Stuffy feeling in the ear 耳闭气? Tinnitus 耳鸣? Outophony 自声过强? Nasal obstruction (blockage) 鼻塞? Dryness of the nose 鼻干燥? Rhinorr
50、hea (Snivel;Nasal discharge) 流鼻涕? Sneezing 打喷嚏? Snoring 打鼾? Hyposmia (Reduction of the sense of smell) 嗅觉减退名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 11 页，共 21 页 - - - - - - - - - ? Anosmia (Complete loss of sense of smell) 嗅觉丧失? Dysphonia 发音困难? Hoarseness 声嘶? Pa