中英文对照病例

POMR (Problem-Oriented Medical Records)表格式住院病历
Biographical data:
一般项目：
Name Age Sex Marital status Nativity Race
姓名 年龄 性别 婚否 籍贯 民族
Occupation Date of admission Informant History
职业 入院日期 病史叙述者 病史
Chief complaint
主诉
History of present illness
现病史
Past history
既往史：
Previous health status: well ordinary bad Infectious diseases
平素健康状况： 良好 一般 较差 传染病史
Immunizations Allergies: N Y clinical manifestation
预防接种史 过敏史 无 有 临床表现
allergen: Trauma: Surgery:
过敏原 外伤史 手术史
Review of systems:(Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy)
系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过)
Respiratory system:
呼吸系统
Sore throat chronic cough sputum hemoptysis wheezing
咽痛 慢性咳嗽 咳痰 咯血 哮喘
dyspnea chest pain
呼吸困难 胸痛
cadiovascular system:
循环系统
Palpitation dyspnea on exertion hemoptysis syncope
心悸 活动后气促 咯血 晕厥
edema of lower limbs precordial pain hypertention
下肢水肿 心前区疼痛 高血压
Digestive system:
消化系统
Anorexia sour regurgitation belching nausea vomitting
食欲减退 反酸 嗳气 恶心 呕吐
abdominal distention abdominal pain constipation diarrhea
腹胀 腹痛 便秘 腹泻

hematemesis melena hematochezia jaundice
呕血 黑便 便血 黄疸
Urinary system:
泌尿系统
Lumbago frequent micturition urgent micturition urodynia
腰痛 尿频 尿急 尿痛
dysuria hematuria nocturia polyuria oliguria facial edema
排尿困难 血尿 夜尿 多尿 少尿 面部水肿
Hematopoietic system
造血系统
Fatigue dizziness blurred vision gingival bleedig
乏力 头昏 牙龈出血

subcutaneous hemorrhage ostealgia epistaxis
皮下出血 骨痛 鼻衄
Metabolic and endocrine system:
代谢及内分泌系统
Excessive appetite anorexia sweats cold intolerance
食欲亢进 食欲减退 多汗 畏寒
polydipsia tremor hands change of character obvious obesity
多饮 双手震颤 性格改变 显著肥胖

emaciation hirsutism hair losing pigmentation
消瘦 多毛 毛发脱落 色素沉着
chang of sexual function amenorrhea
性功能改变 闭经
Musculoskeletal system
肌肉骨骼系统
Floating arthralgia arthraliga swelling of joints
游走性关节痛 关节痛 关节红肿
deformiteies of jionts myalgia atrophy of muscle
关节变形 肌肉痛 肌肉萎缩
Nervous system
神经系统
Dizziness headache vertigo syncope degeneration of memory
头昏 头痛 眩晕 晕厥 记忆力减退
visual disturbance insomnia disturbance of consciousness
视力障碍 失眠 意识障碍
tremor spasm paralysis paresthesia
颤动 抽搐 瘫痪 感觉异常
Personal history:
个人史
Birthplace Occupation sexual history smoking N Y
出生地 职业 冶游史 吸烟 无 有
about years average pieces per day ceased for years
约 年 平均 支/日 戒烟 年
alcohol intake N occasional frequent about years
嗜酒 无 偶有 经常 约为 年
average ml per day others
平均 ml/日 其他
Marital history:
婚姻史：
Marrying age companion’s state of health
结婚年龄 配偶健康状况
Menorrhea and Childbearing:
月经及生育史
Menarche age cycle lasting for days date of last period
初潮 每次持续时间 末次月经时间
(age of menopause)
绝经年龄
Amount of flow: little normal large menstrual pain: N Y
经量 少 正常 多 痛经 无 有
cycle: regular irregular pregnancy times natural labor
经期 规则 不规则 妊娠 次 顺产
times abortions times premature delivery times
胎 流产 胎 早产 胎
stillbirths times difficult labor and its condition
死产 胎 难产及病情
Familly history (pay attention to the congenital diseases and
communicable diseases and communicable dieases related to the paitent
家族史 （注意与患者现病有关的遗传病和传染性疾病）
Father: still alive illness died cause of deaths mother:
父：健在 患病 已故 死因 母 still alive illness died cause of death siblings: others:
健在 患病 已故 死因 兄弟姐妹 子女其他

Physical examination体格检查
Vital signs生命体征:
Temperature体温
pulse脉搏 /min次/分
respiration呼吸 /min次/分
B.P血压 mmHg
General Appearance一般状况:
Development发育:
ortho-sthenic type正常
asthenic type不良
sthenic type超常
nutrition营养:
well良好
fairly中等
poor不良
cachexia恶病质
Facial features面容:
normal无病容
acute急性
chronic慢性病容
others其他
Expression表情:
natural自知
painful痛苦
anxious忧虑
dreadful恐惧
indifferent淡漠

Position: active semi-recumbent others
体位： 自主 半卧位 其他
Gait: normal abnormal
步态 正常 不正常
Conciousness: aware somnolence confusion stupor coma
神志 清楚 嗜睡 模糊 昏睡 昏迷
delirium coppperatio; well badly
谵妄 配合检查 合作 不合作
Mucocutaneous color: normal red pale cyaosis stainted
皮肤粘膜 色泽 无病容 潮红 苍白 紫绀
yellow pigmentation lesions:N Y (type and distribution)
黄染 色素沉着 皮疹 无 有（类型及分布）
Subcutaneous hemorrhange: N Y(type and distribution)
皮下出血 无 有（类型及分布）
Hair: normal reduced edema: N Y(position and degree)
头发分布 正常 减退 水肿 无 有（部位及程度）
Hepatic palm: N Y spider angionma:N Y（position numbers ） others:
肝掌 无 有 蜘蛛痣 无有(部位 数目) 其他
Lymphnodes:
淋巴结
Superficial lymph nodes: non-swelling swelling(position and characteristics)
全身淋巴结肿大 无肿大 肿大（部位及特征）
Head : cranium : size : normal large small deformity:
头部 头颅 大小 正常 大 小 畸形
N Y(coxycephaly squared skull deforming skull)
无 有（尖颅 方颅 变形颅 ）

Others: tenderness mass sunk (position)
其他异常：压痛 包块 凹陷（部位）

Eyes eyelid: normal edema ptosis trichiasis conjunctive :
眼睑 正常 水肿 下垂 倒睫 结膜
normal hyperemia edema hemrrhage
正常 充血 水肿 出血
eye ball: normal proptosis depression tremor
眼球 正常 突出 凹陷 震颤
motion dysfunction(left right)
运动障碍
Sclera :normal yellow cornea : normal abnormal ( left right )
巩膜 无黄染 有黄染 角膜 正常 异常 （左 右 ）
Pupils: equal roundness same size unequal left cm
瞳孔 等圆 等大 不等 左 cm
reaction to light: normal delay (left right) disappear (left right) 对光反射 正常 迟钝（左 右） 消失 （左 右）
Others:
其他
Ears: auricle :normal deformity fistula others (left right )
耳 耳廓 正常 畸形 瘘管 其他 （左 右）

excretions of external auditory canal: N Y (left right feature)
外耳道分泌物 无 有（左 右 性质）
Tenderness of mastoid : N Y audation dysfunction: N Y (left right)
乳突压痛 无 有 听力粗试障碍 无 有（左 右）
Nose: shape : normal: abnormal ( ) other abnormalities:N Y
鼻 外形 正常 异常 （ ） 其他异常 无 有
Nosalala flap obsruction excretions nasal sinus tenderness:
鼻翼扇动 鼻塞 分泌物 鼻旁窦压痛
N Y (position )
无 有（部位）
Mouth lips :red syanosis pale herpes fissure mucosa :normal
口唇 红润 发绀 苍白 疱疹 皲裂 粘膜 正常
abnormal ( pale petechia)
异常 （苍白 出血点）
Opening of parotid gland duct: normal abnormal (swelling
腮腺导管开口 正常 异常 （肿胀
suppurative excretions)
脓性分泌物）
Tongue:normal abnormal (coverings tremor leaning to left or right)
舌 正常 异常 （舌苔 伸舌震颤 向左、向右偏斜）
Gums: normal swelling pus overflow hemorrhage pigments
牙龈 正常 肿胀 溢脓 出血 色素沉着
lead line tooth:regular edentulous carious teeth
铅线 牙列 齐 缺牙—|— 龋齿—|—
Tonsils: pharynx: voice: normal hoarse
扁桃体 咽 声音 正常 嘶哑
Neck:resistence:N Y carotid artery pulsation: normal increased
颈部 抵抗感 无 有 颈动脉搏动 正常 增强
decreased (left right) jugular vein:normal distention
减弱 （ 左 右 ） 颈静脉 正常 充盈
high distention trachea:middle deviation to (left right)
怒张 气管 正中 偏移 （向左 向右）
Hepatojugular reflux:(-) (+) thyroid: normal swelling degree
肝颈静脉回流征： （-）（+） 甲状腺 正常 肿大 度
Symmetry 对称
Dominance in one side: spreading nodular:soft hard others :N Y
侧为主 弥漫性 结节性 质软 质硬 其他 无 有
(tenderness tremor bruits)
（压痛 震颤 血管杂音）
Chest topography:normal barrel chest pigeon chest funnel chest
胸部 胸廓 正常 桶状胸 鸡胸 漏斗胸
flat chest bulging or retraction (left right )
扁平胸 膨隆或凹陷 （左 右 ）

bulging in the precordial region tenderness of sternum
心前区膨隆 胸骨压痛
Breast: normal symmetrical abnormal : left right(gynecomastia
乳房 正常对称 异常 左 右（男乳女化
mass tenderness excretions of nipples)
包块 压痛 乳头分泌物）
Lung
肺
Inspection : movement of respiration : normal abnormal : left
视诊 呼吸运动 正常 异常 左
right( increased decreased)
右 （增强 减弱 ）
Intercostal space :normal wide narrow(position)
肋间隙 正常 增宽 变窄（ 部位 ）
Palpation : vocal fremitus:normal abnormal :left right (increased
触诊 ： 语颤 正常 异常 左 右 （增强
decreased ) pluernal friction rubs: N Y（position）
减弱 胸膜摩擦感： 无 有（部位）
Subcutaneous crepitus: N Y(posotion) percussion: resonance
皮下捻发感 无 有（部位） 叩诊 正常清音
abnormal dullness flatness hyperresonance tympany
异常叩诊音 浊音 实音 过清音 鼓音
Lower borders:scapular line: right intercostal space, left
肺下界 肩胛线 右肋间 左
intercostal space Range of mobility: right cm , left cm
肋间 移动度 右 cm， 左 cm
Dusculation: breath regular irregular
听诊 呼吸 规整 不规整
Breath sound: normal abnormal( feature, position )
呼吸音 正常 异常 （性质， 部位描写）
Rale: N Y ：ronchi: sonorous sibilant
啰音：无 有： 干性 鼾音 哨笛音
Moist rales: coarse medium fine rales crepitus
湿性 大 中 小水泡音 捻发音
Vocal conduction: normal abnormal: reduced increased(position)
语音传导 正常 异常 减弱 增强 （部位）
Plueral friction rubs: N Y (position)
胸膜摩擦音 无 有（部位）
Heart 心
Inspection:bulging in precordial region : N Y apex impulse:
视诊 心前区隆起 无 有 心尖搏动
normal unseen increased diffusing position: normal
正常 未见 增强 弥散 心尖搏动位置 正常

deviation ( the distance from midclavicular line cm)
移动 （距左锁骨中线内外 厘米）
Other precordial pulsations: N Y (position)
其他部位搏动 无 有（部位）
Palpation:apex impulse:normal increased thrust unclear
触诊 心尖搏动 正常 增强 抬举感 触不清
thrills :N Y (position period) percardial friction rubs:N Y
震颤 无 有（部位 时期 ） 心包摩擦感 无 有
Percussion:relative cardiac outline: normal shrink extant (right left )
叩诊 相对浊音界 正常 缩小 扩大（右 左 ）
Ausculation: heart rate bpm/min rhythm(regular irregular
听诊 心率 次/分 心律 （齐 不齐 ）
absolutly irrgelar) heart sound:S1 normal increased decreased
绝对不齐 心音 S1 正常 增强 减弱
split S2 normal increased decreased split
分裂 S2 正常 增强 减弱 分裂
S3 N Y S4 N Y A2 P2
S3 无 有 S4 无 有 A2 P2
Extra heart sound N gallop (diastolic presystotic summalion
额外心音 无 奔马律（舒张期 收缩前期 重叠
gallop) opening snap others murmurs: N Y (degree conduction)
开瓣音 其他 杂音 无 有（图示并描述传导）
Pericardial friction rubs N Y
心包摩擦音 无 有
Peripheral vessals: normal pistal shot of big arteries
周围血管 无异常血管征 大血管枪击音
Duroziez’s sign water hammer pulse capillary pulsation
二重杂音 水冲脉 毛细血管搏动
pulse deficit paradoxical pulse pulsus alternans other
脉搏短绌 奇脉 交替脉 其他
Abdoman
腹部
Inspection: shape normal distention frog abdomen( size cm)
视诊 外形 正常 膨隆 蛙腹 （腹围 厘米）
scaphoid apical abdomen gastral pattern intestinal pattern
舟腹 尖腹 胃型 肠型
peristalsis abdominal respiration:existance disappear umbilicus:
蠕动波 腹式呼吸 存在 消失 脐
normal protruding excretions others: N Y(venous distention of
正常凸出 分泌物 其他异常 无 有（腹壁静脉曲张
abdoman purple striae surgical scars hernia)
条纹 手术疤痕 疝）
Palpation: soft muscle tension position tenderness N Y
触诊 柔软 腹肌紧张 部位 压痛 无 有rebound tenderness N Y fluidthtill N Y succussions plash N Y
反跳痛 无 有 液波震颤 无 有 振水音 无 有
Mass N Y(position size) discription of feature liver:can’t be 腹部包块 无 有（部位 大小） 特征描述 肝 未触及
touched can be touched :subcostal cm under xipfoid process
可触及 肋下 厘米 剑突下
discription of feature gallbladder: can’t be touched can be touched
特征描述 胆囊 未触及 可触及
size cm tenderness N Y Murphy’s sign spleen: can’t be 大小 厘米 压痛 无 有 Murphy征 脾 未触及
touched can be touched distance from costal margin cm
可触及 肋下 厘米
Kideny:can’t be touched can be touched size consistency
肾 未触及 可触及 大小 硬度
tenderness mobility tenderness of ureters: N Y (position)
压痛 移动度 输尿管压痛点 无 有（部位）
percussion: borders of liver dull(existance shrink obliteration )
叩诊 肝浊音界 （存在 缩小 消失 ）
Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线 肋间
shifting dullness N Y tenderness in renal region N Y (right left )
移动性浊音 无 有 肾区叩痛 无 有（右 左）
ausculation : borhorygmus normal increased decreased
听诊 肠鸣音 正常 增强 减弱
disappear gurgling N Y vessal bruits N Y (position)
消失 气过水声 无 有 血管杂音 无 有 （部位）
Genitalia :not examined normal abnormal Rectum and Anus :
生殖器 未查 正常 异常 肛门直肠
not examined normal abnormal
未查 正常 异常
Spine and Extremities
脊柱四肢
Spine : normal deformities (lateral anterior posterior protruding)
脊柱 正常 畸形 （侧 前 后凸 ）
Spinous process : tenderness pain while percussed ( position )
棘突 压痛 叩痛 （部位）
Mobility : normal restricted extremeties: normal abnormal
移动度 正常 受限 四肢 正常 异常
deformity swelling of joints joints stiffness
畸形 关节红肿 关节强直
tenderness of muscles atrophy of muscles
肌肉压痛 肌肉萎缩
Venous distention of lower limbs (position and feature ) acropachy
下肢静脉曲张 （部位及特征） 杵状指

Nervus System
神经系统
Abdominal wall reflex ( normal ) muscle tone ( normal )
腹壁反射 （正常） 肌张力 （正常）
Myodynamia ( degree ) paralysis of limbs N Y (left right
肌力 （ 级 ） 肢体瘫痪 无 有（左 右
upper lower) biceps reflex left (normal) right (normal)
上 下 ） 肱二头肌反射 左（正常） 右 （正常 ） knee jerk left (normal) right( normal) achilles jerk left
膝健反射 左（正常） 右 （正常） 跟腱反射 左
(normal) right ( normal )
正常 右 （正常）
Hoffmann’s dign left (+)(-) right(+)(-)
Hoffmann征 左（+）(-) 右（+）（-）
Babinski’s sign left(+)（-） right(+)(-)
Babinski 左（+）（-） 右（+）（-）
Kernig’s sign left(+)（-）right(+)(-) others
Kernig征 左（+）（-） 右（+）（-） 其他
Laboratory findings
实验室及器械检查结果

（The important laboratory examination .X-ray . ECG and other result areincluded） (重要的化验、X线、心电图及其他有关化验) Nunber of X-ray
X线片号
Abstract
病历摘要
Diagnosis(impressions)
入院诊断



Recorder
病史记录者
Examiner
并使审阅者
Date of record
记录日期

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*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] •***[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] •***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*程度的表示方法 • [Reliable] 可* • [Unreliable] 不可* • [Not entirely] 不完全可* • [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***
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 (Sputum;Phlegm)] 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*
• [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
• [A***uality (lack of libido)] 无性欲
• [Hypo***uality] 性欲低下
• [Hyper***uality] 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
• [Ophthalmodynia (Eye-ache;ocular pain)] 眼痛
• [Photophobia] 畏光
• [Spots before the eyes] 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
• [Rhinorrhea (Snivel;Nasal discharge)] 流鼻涕
• [Sneezing] 打喷嚏
• [Snoring] 打鼾
• [Hyposmia (Reduction of the sense of smell)] 嗅觉减退
• [Anosmia (Complete loss of sense of smell)] 嗅觉丧失
• [Dysphonia] 发音困难
• [Hoarseness] 声嘶
• [Pain on swallowing] 吞咽痛
• [Saliva dribblies from the mouth] 流涎
• [Troaty voice] 声音沙哑
• [Stridor] 喘鸣
• [Red and swollen] 红肿
• [Scurf] 头皮屑
• [Show] 见红
• [Amniotic fluid escaped] 破水
• [Uterine contraction] 宫缩
• [Acalculia] 计算不能
• [Apathy] 情感淡漠
• [Delusion] 妄想

第三章 现病史[History of present illness (HPI/PI)]

现病史书写的重点包括：
一、主诉中症状的详细描述；
二、疾病的发展过程；
三、诊疗经过；
四、目前的一般情况。
1、诱因
•无诱因下[With no inducing factors]
•无明显诱因下[Under no obvious predisposing causes]
•感冒一周后[After getting (catching) common cold for 1 week]
2、症状出现的叙述
•有……症状
▲suffer from
▲ have an attack of
▲ have(fell)
▲ begin to fell
▲ a feeling (sensation) of……
▲ complain (of)
▲ ……sensation (feeling) in (of) ……
▲ [发热]have a temperature (become feverish)
•在……情况下发生
▲ 活动时呼吸困难[dyspnea on exertion]
▲ 躺下后即出现咳嗽[Cough occurs soon after lying]
•与……有（无）关
▲ 与……有关[be associated with]
▲ 与……有关[have (make) relation to]
▲ 与……无关[have (make)no relation to]
•在……情况下加重（减轻）
▲ 餐后加重[become worse after taking meals]
▲ 站立后缓解[be relieved by standing up]
▲ 随呼吸和咳嗽而加重[become more severe with breathing and cough]
•伴有……
▲ be accompanied by

3、起病方式
•急性腹痛[acute abdominal pain]
•慢性低热[chronic lower fever]
•暴发性发病[the onset was fulminating]
•骤起胸痛[an explosive onset of chest pain]
•突然起病伴高热[the onset was sudden with high fever]
•突发突止[attacks began and ended abruptly]
•因……而突然起病[the attack is precipitated by……]
•很快发生晕厥[syncope occured rapidly]
•逐渐出现咳嗽咳痰[gradual onset of cough and sputum]
•偶而[occasionally (sporadically, accidentally)]
•反复胸闷心悸[recurrent (bouts of) chest discomfort and palpitation]
•一过性发作[transitory attack]
•连续胸痛[chest pain continually]
•时重时轻[waned and waxed]
•时好时坏[hang in the balance]
•不停地咳嗽[have a fit of cough]
•发作性呼吸困难[paroxysmal short of breath]
•频繁咳嗽[cough frequently (very often)]
•持续性（间歇性）[persistent (intermittent)]
•频发胸痛[frequent episodes of chest pain]
•持续不变[be steady]
4、病情变化描述
•[症状好转] ▲fell better than before
▲take a favorable turn
▲take a turn for the better
▲improve
▲make favorable progress
▲turn for the better
▲change for the better
▲be better
•[症状减轻] ▲alleviate
▲reduce
▲palliate
▲diminish
▲ease(lighten)
▲mitigate
•[症状消失] ▲disappear
▲subside
▲regress
▲clear up
▲vanish
▲dissolve
▲die (fade) away
▲relieve
•[症状加重] ▲be (make,become,get) worse
▲worsen
▲become more severe
▲take a turn for the worse
▲be aggravated
▲increase in severity
▲take a bad turn
▲make (become) more serious
▲make (become) heavier
•[无变化] ▲remain the same as……
▲continue without change
▲be identical
▲be alike
▲be similar
▲resemble
•[时好时坏] ▲wane and wax
▲hang in the balance
•[体温/血压升降]
▲ 升至[rise (go up) to ]
▲ 已升至[have risen (gone up) to ]
▲ 从……升至……[go up from …… to……]
▲ 升至[be elevated to]
▲ 迅速下降[fall (decline, abate) abruptly]
▲ 骤降（升）[sudden drop (elevation)]
▲ 渐降（升）[fall (elevate) gradually]
▲ 缓慢下降[slow crisis (lysis) of ]
▲ 一天天下降[be (become) lower day by day]
▲ 开始降低[begin to remit]
▲ 降至正常[drop (was reduced) to normal]
▲ 已降至[have gone down (dropped) to]
▲ 回复到正常[return (revert) to normal]
▲ 由……降（升）至……[fall (elevate) from……to……]
▲ 维持在……水平[maintain at a level of……]
▲ 稳定在……[stabilize at……]
▲ 热退了[fever disappeared]
▲ 不超过[do not go up over (exceed)……]
▲ 在……和……之间波动[fluctuate (vary) between……
and……]
▲ 在……至……范围内[range from……to……]
▲ 平均38.5℃[an average temperature of 38.5℃]
▲ 有39.2℃的体温[have fever (a temperature) of 39.2℃]
5、症状的时间表示
•持续 ▲lasted for 2 days
▲have gone on for 1 month
▲have continued for 10 hours
▲lasted on the average 3-5 hours
▲lasted a variable time from 5 minutes to several hours
▲lasted about half an hour
•超过（不到）[move than (less than)]
•……以前[two years ago]
•多在……时发生[usually between 3 and 5 PM]
•未发作过[be free of onsets (attacks) for 2 weeks]
6、症状的严重程度
•轻度[mild (slight)]
•中度[moderate]
•重度[severe (serious)]
7、症状的其他描述方法
•[部位] ▲be located (situated) in (over)[位于]
▲There is localized pain in……[疼痛位于]
▲near……[在……附近]
▲be localized to (in, over)[局限于]
▲be limited (confined) to[局限于]
•[表示部位的介词]
▲心尖部，表示小的部位或点[at the apex]
▲上腹部，表示大的部位[in the upper abdomen]
▲在左下肢，表示皮肤表面上（下）的病变[on (beneath) the
left lower limb]
▲在右肺，表示正上方的相应体表部位[over the right lung]
▲嘴上（下）方，表示高低或上下的位置关系[above (below)
the mouth]
▲左乳皮下[under the skin of the left breast]
•[转移/放射]
▲转移到……[shift (migrate) to……]
▲放射到……[radiate (travel,go,refer)to……]
▲从……放射到……[radiate from……to……]
•[耳鼻咽喉及口腔症状]
▲耳痛[otalgia (pain of ears)]
▲耳鸣[tinnitus (ears ring)]
▲耳鸣[a buzzing (ringing,singing) in the ears]
▲左耳有耳鸣感[a buzzing sensation in the left ear]
▲耳聋[deafness (loss in hearing)]
▲左耳聋[be deaf of the left ear]
▲耳流脓[otorrhea (otopyorrhea)]
▲耳出血[otorrhagia]
▲耳垢[cerumen (earwax)]
▲耳血肿[othematoma]
▲鼻塞[nasal obstruction]
▲不能用鼻呼吸[be unable to breathe through (by) the nose
(nasal dyspnea)]
▲打喷涕和流涕[sneezing and nasal discharge]
▲水样鼻涕[watery rhinorrhea]
▲鼻出血[nosebleed]
▲咽喉痛[sore throat]
▲口吃[stuttering]
▲口臭[ozostomia (saburra,halitosis)]
▲张口困难[difficult (inability) to open the mouth]
▲张口（吞咽、嚼）困难[difficult in opening the mouth
(swallowing，masticating)]
▲咽下困难[dysphagia]
▲流涎多[have excessive salvation]
•[眼科及牙科症状]
▲眼睑浮肿[eyelid edema]
▲眼痛[pain in the eyes]
▲视边模糊[blurring of vision (blurred vision)]
▲过度流泪[excessive tearing (watering)]
▲视疲劳[asthenopia (visional tired)]
▲视力减退[hypopsia (diminution of vision)]
▲视力衰弱[ophthalmocopia]
▲远（近）视力模糊[indistinct distant (near) vision]
▲失明[loss of vision]
▲搏动性牙痛[throbbing pain of tooth (odontalgia)]
▲牙龈出血[gingival bleeding]
▲牙龈萎缩（增生）[gingival atrophy(hypertrophy)]
▲牙周溢脓[peripyema]
•[妇产科症状]
▲月经过多[excessive menstrual flow (menorrhagia)]
▲月经多并伴血块[experience menorrhagia with passage of
clots]
▲经量少（中等、多）[mild (moderate,heavy) menses]
▲月经过少[hypomenorrhea]
▲阴道出血[vaginal bleeding(colporrhagia)]
▲阴道大出血[massive (profuse) vaginal bleeding]
▲无痛性（性交后）阴道出血[painless(postcoital) vaginal
bleeding]
▲阴道干燥[colpoxerosis]
▲月经规则（不规则）[rugular (irregular) menstrual cycle]
▲月经周期26天，持续4天[menstrual periods of 26 days and
lasted 4 days]
▲白带增多[leukorrhagia (profuse leukorrhea or whites)]
▲外阴搔痒[pruritus of vulva]
▲外阴湿疹（白斑）[eczema (leukoplakia) of vulva]
▲绝经[amenorrhea]
▲停经[menopause]
▲停经3年[3 years post menopausal]
▲50岁停经[Passed menopause at age 50]
▲经前（期）痛[pain before (during) the flow]
▲预产期[expected date of confinement]
▲见红和破水[show and amniotic fluid escaped (rupture of
membranes)]
▲羊水过多（少）[polyhydramnios (oligohydramnios)]
▲月经期水肿[menstrual edema]
▲月经失调[menstrual disorder]
▲性欲正常（减退）[normal(decreased) libido]
▲无性欲[loss of libido]
▲性功能障碍[***ual disorder]
▲性变态[paraphilia]
▲性要求高（低）[be over***ed(under***ed)]
▲性感不快[dypareunia]
▲性欲亢进（减退）[hyper***uality (hypo***uality)]
▲产程[stage of labor]
▲产程延长[prolonged labor]
▲产道裂伤（损伤）[laceration (injury) of birth canal]
▲产后腹痛（出血，尿潴留，子痫）[postpartum tormina
(hemorrhage,retention of urine, eclampsia)]
▲产前出血[antepartum hemorrhage]
▲产前子痫[prenatal eclampsia]
▲产前检查[prenatal examination]
▲产褥热[puerperal fever]
▲产褥期护理[pureperal care]
▲妊娠呕吐[vomiting of pregnancy (hyperemesis gravidarum)]
▲妊娠反应[pregnancy reaction]
▲妊娠高血压（水肿）[gestation hypertension (edema)]
•[病程中的一般情况]
▲一般情况尚可（一般、差）[general condition is fair (ordinary, bad)]
▲胃纳佳（差）[have a good (poor) appetite]
▲过度进食[eat too much (overeat, eat heavily)]
▲过少进食[eat poorly (take little food)]
▲无食欲[have no appetite]
▲食欲减退[appetite decreases]
▲口渴[feel thirsty]
▲大量饮水[drink water generously]
▲体重增加[gain in weight]
▲体重增加8公斤[a 8 kilograms weight gain (gain 8 kilograms)]
▲体重减轻[loss of weight (weight loss)]
▲体重稳定不变[body weight is stable (unchanged, maintained)]
▲睡眠障碍[somnipathy]
▲睡眠不足[lack (want) of sleep]
▲不易入睡[have trouble getting to sleep]
▲容易入睡[fall into a sleep very easily]
▲睡眠过度[hypersomnia]
▲睡行症[sleep walking]
▲嗜（贪）睡[somnolence (be fond of sleep)]
▲夜晚因……而易醒[easily wakened at night because of……]
▲失眠[have insomnia]
▲睡眠差（好）[sleep is poor (good)]
▲消化不良[dyspepsia (have bad digestion)]
▲大（小）便通畅[stool (urination) is easy and smooth(unobstructed, clear)]
▲每日2次大便[have two stools daily]
▲含粘液的水样便[watery stools coutaining mucus]
▲便秘（腹泻）[constipation (diarrhea)]
▲排尿困难[difficulty in micturition]
▲尿频（急）[frequency(urgency) of micturition]
▲尿痛[micturition pain]
▲少尿（无尿、多尿）[oliguria (anuria, polyuria)]
▲大便失禁[fecal incontinence]
▲小便失禁[incontinence of urine]
▲精神不振[lassitude]
▲精神紧张（抑郁）[mental stress (depression)]
▲精神混乱[confusion]
▲精神失常[amentia (mental state is bad)]
▲精神状态正常[orthophrenia (mental state is good)]
▲体力旺盛（不足，正常）[hypersthenia (hyposthenia, euthesia)]

第四章 过去史、系统回顾和个人史
（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.]
•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 (***ual 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)]

第五章 月经、婚姻、生育史和家族史
[Menstrual, marrital and childbearing history and family history]
1、月经史[menstrual history]
•初潮年龄[age of menarche]
•月经周期[menstrual cycle]
•行经期[menstrual period]
•未次月经时间[last menstrual period (LMP)]
•闭经年龄[age of menostasis]
•白带过多[profuse leukorrhea (whites)]
•月经过多[menorrhagia (hypermenorrhea, menometrorrhagia)]
•月经过少[hypomenorrhea (scantymenstruation)]
•月经过频[polymenorrhea]
•月经稀发[oligomenorrhea]
•月经不调[menoxenia (irregular menses, menstrual disorder)]
•月经正常[eumenorrhea (regular menses)]
•经前水肿（疼痛）[premenstrual edema (pain)]
•经量少（中、大）量[mild (moderate, heavy) meustrual blood]
•痛经[dysmenorrhea (pain during the flow)]
•36岁就停经了[pass the menopause at age 36]
2、婚姻史[marrital history]
•未婚（已婚）[single (married)]
•结婚年龄[age of wedding]
•配偶的健康状况[health status of partner (spouse)]
•性生活和谐（不和谐）[***ual life is harmonious (disorder)]
•夫妻关系和睦（不和睦）[relation of husband and wife is amicable (hostile)]
•近亲（非近亲）结婚[consanguineous (nonconsanguineous) marriage]
3、生育史[childbearing history]
•妊娠（生育）次数和年龄[times and age of pregnancy (childbearing)]
•怀孕和生产次数[pregnancies and labors]
•人工（自然）流产次数[times of induced (spontaneous) abortion (miscarriage)]
•流产 [miscarriage(abortion)]
•死胎（产）[dead fetus (birth)]
•割腹产[caesarean birth (be born by caesarean section)]
•子女数[number of children]
•早产（儿）[premature birth (bady)]
•足月产[term labor]
•产褥热（感染）[puerperal fever (infection)]
•计划生育[family planning (birth control)]
•用避孕环（药、油膏、套、栓）避孕[contraception by intrauterine ring (contraceptives, ointment, condom, supposity)]
•节育手术[contraceptive operation]
•自然分娩[be delivered normally and spontaneously(spontaneous labor)]
•产钳分免[forceps delivery(be delivered by forceps)
•产前（后）子痫[antepartum(postpartum) eclampsia]
•出生时3.5公斤重，48厘米高[3.5 kilograms and 48cm in height at birth]
•母乳喂养[breast feeding (be fed at breast)]
•人工喂养[artificial feeding]
•发育正常[normal development]
•发育异常(停顿、缺陷、畸形)[developmental anomaly(arrest,defect,deformity)]
•发育迟缓（过渡）[hypoevolutism(hypergenesis)]
4、家庭史[family history]
•父母（兄弟，姐妹和儿女）的健康状况和疾病情况[health status and illness
of parents (brothers,sisters and children)]
•同样疾病[the same sickness]
•遗传疾病[heredopathia (genetic disease)]
•遗传特征[hereditary feature]
•死因[cause of death]
•健康[be healthy (be in good healthy)]
•健在[be living and well]
•无……家族史[no family history of ……]
•死于……[die of……]

第六章 体检（一般项目）[Physical examination(general items)]
•视诊[inspection]
•触诊[palpation]
•叩诊[percussion]
•听诊[auscultation]
•嗅诊[olfactory examination]
•浅（深）触诊法[light (deep) palpation]
•深部滑行（深压，双手，冲击）触诊法[deep slipping (deep press,bimanual,ballottement]
•间接（直接）叩诊[indirect (direct) percussion]
•叩诊音（过清音，清音，浊音，鼓音，实音）[percussion sound (hyperresonance,resonance,dullness,tympany,flatness)]
•用钟（膜）型胸件听诊[with the bell (diaphragmatic) chestpiece ]
1、体温[temperature, T]
•口（腋、肛）温[oral (axillary, rectal) temperature]
•经口（腋、肛）测的温度[per mouth (axilla, rectum)]
•摄氏与华氏换算[Centigrade VS Fahrenheit]
℃=5/9(℉-32)
℉=9/5℃+32
℃～℉ ℃～℉
36.5～97.7 38.5～101.3
37.0～98.6 38.9～102.0
37.2～99.0 39.0～102.2
37.5～99.5 39.4～103.0
37.8～100 40.0～104.0
38.0～100.4 40.5～104.9
38.3～101.0 41.0～105.8
•37.5℃.orally(99.5℉)[口温摄氏37.5度（华氏99.5度）]
2、脉搏[pulse, P]
•脉率72次/分[pulse 72 beats per minute(P 72 bpm)]
•搏动存在（消失）[pulse are present (absent)]
•速（缓）脉[fast (slow) pulse]
•洪（细丝）脉[bounding (small, thready) pulse]
•水冲脉[water hammer pulse]
•交替脉[alternating pulse]
•奇脉[paradoxical]
•二联（三联）脉[bigeminal (trigeminal) pulse]
•重脉[dicrotic pulse]
•间歇脉[intermittent pulse]
•陷落脉[collapsing]
•不规则（规则）脉[irregular(regular) pulse]
3、呼吸[respiration, R]
•呼吸频率[respiratory rate (RR)]
•呼吸频率19次/分[RR 19 beats/min (R 19 bpm)]
•规则（不规则）呼吸[regular (irregular) breathing]
•呼吸均匀[eupnea]
•呼吸急促（缓慢）[repid (slow) breathing]
•呼吸停止（中断）[pausal (interrupted) breathing]
•呼吸骤停[breath arrest]
•深（浅）呼吸[deep (superficial) breathing]
•呼吸困难[dyspna (short of breath)]
•呼吸费力[labored breathing]
•胸（腹）式呼吸[thoracic (abdominal) breathing]
•张口呼吸[mouth (buccal) breathing]
•周期性呼吸[periodic respiration]
•库斯毛氏呼吸[Kussmaul`s respiration]
•陈-施（潮式）呼吸[Cheyne-Stokes (tidal) respiration]
•间歇呼吸[Biot`s breathing]
•叹息样（胎儿,鼾样）呼吸[sighing (fetal, stertorous) respiration]
•口臭[have foul (fetid) breath (halitosis)]
•酮味呼吸[a smell of ketone]
•静息下（活动时）气促[dyspnea at rest (on exertion)]
•丙酮（氨臭，蒜臭）味[acetone (ammoniacal, alliaceous) odor]
•肝臭[hepaticus fetor]
•腋臭[bromidrosis]
4、血压[blood pressure, BP]
•收缩（舒张）压[systolic (diastolic) blood pressure]
•血压20/12千帕（150/90毫米汞柱）[BP 20/12 kPa(150/90mmHg)]
1kPa=7.5mmHg (1mmHg=0.1333kPa)
•血压为收缩压20，舒张压12千帕[Bp is 20 over 12 (Bp is 20 systolic and 12 diastolic)]
•测量血压[take (measure, check ) Bp]
•坐（卧）位血压[sitting (lying) Bp]
•无创（有创）血压[non-invasive (invasive) Bp]
•脉压[pulse pressure]
•血压测不出[Bp is unavailable (unobtained)]
•左臂（右臂）血压[Bp in left (right) arm]
•双下肢血压[Bp in both lower limbs]
•袖带[cuff]
5、体位[position]
•主动（被动、强迫）体位[active (passive, forced ) position]
•立（坐、卧）位[upright (sitting, dorsal) position]
•仰卧（俯卧）位[supine (prone) position]
•左（右）侧卧位[left (right) lateral (decubitus) position]
•蜷腿位[coiled position]
•半卧位[semi-reclining (semi-recumbent) position]
•端坐位[orthopnea position]
•胸膝（膝肘）位[knee-chest (knee-elbow) position]
•截石（分娩）位[dorsosacral (obstetric) position]
•角弓反张位[opisthotonus position]
•强迫蹲位[compulsive squattin]
•辗转体位[alternative position]
•头高（低）脚低（高）位[high (low) head and low(high) legs]
6、神志和意识[consciousness and mind]
•清醒（半清醒的）[alert (semi-conscious)]
•昏迷（半昏迷）的[comatose (semi-comatose)]
•无精打采的[listless]
•思睡的[somnolent (drowsy, sleepy)]
•昏睡的[lethargic]
•焦虑不安的[anxious (restless, apprehensive)]
•激动的[excited (irritable)]
•精神错乱的[confused]
•意识障碍[distrubance of consciousness]
•谵妄[delirium]
•抽搐[convulsion]
•木僵的[stuporous]
•合作佳（欠佳、差）[cooperation is good (not good enough, bad)]
•反应迟钝[have a dull reaction]
•有（无）定向力[be oriented (disoriented)]
•朦胧状态[be in a mist tent]
•神志模糊[blurred (dim, vague) mind]
•失去知觉[loss consciousness(unconsciousness)]
•对疼痛刺激的反应[reaction to painful stimuli]
7、面容[facial features]
•呈急（慢）性面容[be in acute (chronic) distress]
•病然面容[critical facies]
•濒死面容[hippocratic facies]
•苦笑面容[sardonic facies]
•表情不安 [anxious (distressing) expression]
•神情憔悴[ haggard expression]
•贫血（肾病、肝病）面容[anemic (nephrotic, hepatic) facies]
•二尖瓣（伤寒）面容[mitral (typhoid) facies]
•满月（面具）面容[moon (masked) facies]
•肢端肥大症面容[acromegaly facies]
•甲亢（粘液性水肿）面容[hyperthyroid (myxedema) facies]
•老年貌[senile feature]
•颜面潮红（苍白）[reddy (pale) facies]
•面色红润[florid facies]
8、发育[development]
•身高[body height (length)]
•身材（高大、矮小）[stature (tall, dwarf)]
•体格（强壮、脆弱）[physique (strong, weak)]
•青春期[adolescent spurt]
•体型[habitus]
▲无力（乏力、超力）型[asthenic (ortho-sthenic, sthenic) type]
▲巨人症（重体侏儒症、奄人症）[gigantism (pituitary dwarfism, eunuochism)]
▲运动员体型[athletic type]
▲矮胖（瘦长）型[stocky (lanky) type]
•一位发育良好（中等）的病人[a well (middle)-developed patient]
•发育不良（异常）[hypoplasia (dysplasia)]
•身高171厘米[177cm in height]
9、营养[nutrition]
•营养良好（中等、不良）[well (middle, under)-nourished]
•良好、不良，中等[well (poorly, fairly)]
•肥胖[obesity (overweight,fat)]
•消瘦[emaciation (underweight, thin, lean)]
•恶液质[cachexia]
•水牛背[buffalo hump]
10、姿势与步态[posture and gait]
•共济失调步态[ataxic (incoordination) gait]
•剪刀步态[scissors gait]
•慌张步态[festinating gait]
•跨域步态[steppage gait]
•摇摆步态[swaying gait]
•蹒跚步态[reeling (staggering, waddling) gait]
•闭目难立征[Romberg`s sign]
•间歇性跛行[intermittent claudication]
11、皮肤与粘膜[skin and mucosa]
▲颜色[color]
▲苍白（红色、暗红、潮红、粉红色）[pallor (redness, dusky redness, flush, pinky)]
▲显得苍白[be (look) pale]
▲紫绀（手足发绀）[cyanosis (acrocyanosis)]
▲黄疸（黄染）[jaundice (stained yellow)]
▲黑色素[melanin]
▲色素沉着过多（减退）[hyper pigmentation (depigmentation)]
▲色素沉着增加(减少)[pigmentation increase（decrease）]
▲白癜（白斑）[vitiligo (leukoplakia)]
▲雀斑（老年斑）[fleck (senile plague)]
▲紫（妊娠）纹[purple (pregnant) striae]
▲多血症[be plethoric]
▲重度（中度、轻度）紫绀[be severely (moderately, slightly) cyanosis]
•湿度与弹性[moisture and elasticity]
▲干燥（湿润）的[dry (moist)]
▲湿冷[cold moist]
▲冷（暖、热）[cool (warm, hot)]
▲光滑（粗糙）的[smooth (rough)]
▲光亮的[shing]
▲紧张（松弛）的[taut (loose)]
▲软（硬）[soft (hard)]
▲鳞状（皱纹）的[scaly (wrinkling)]
▲有（无）弹性的[elastic (inelastic)]
▲萎缩（肥厚）的[atrophic (hypertrophic)]
▲皮下气肿[subcutaneous emphysema]
▲全身（局限）性水肿[anasarca (localized edema)]
▲凹陷性（非凹陷性）水肿（加重、减轻、消退）[pitting (non-pitting) edema (increase, decrease, subside)]
•皮损[skin lesions]
▲皮疹[skin eruption]
▲斑疹[maculae]
▲玟瑰疹[roseola (rose spots)]
▲丘疹[papule]
▲斑丘疹[maculopapule]
▲风疹[rubella]
▲疱疹[belbs]
▲斑片[patch]
▲斑块[plaque]
▲荨麻疹[urticaria (hives)]
▲脱皮（屑）[desquamation (excoriation)]
▲蜘蛛痣[spider angioma]
▲皮下小结[subcutaneous nodules]
▲瘢痕[scar]
▲痱子[sudamen]
▲水（血、脓）疱[water (blood, pus ) bpister]
▲小（大）水疱[vesicle (bulla)]
▲单纯疱疹[herpes simplex]
▲风团（囊肿、肿瘤）[wheal (cyst, tumor)]
▲皮屑（鳞屑）[furfur (scale)]
▲结痂（焦痂）[crust (eschar)]
▲溃疡（糜烂、皱裂）[ulcer (erosion, fissure)]
▲肝掌（朱砂掌）[liver (erythema) palms]
▲黄褐斑[chloasma]
▲环形红斑[circinate erythema]
▲黑痣[pigmented nevas]
▲胎记[birthmark]
▲疣（鸡眼）[werruca (clavus)]
▲冻疮[pernio]
▲褥疮[bedsore (decubitus)]
▲渗液[exudate]
•出血[bleeding]
▲瘀点[petechia]
▲紫癜[purpura]
▲瘀斑[ecchymosis]
▲血肿[hematoma]
▲片状出血[splinter hemorrhage]
▲渗血[oozing of the blood]
▲压之褪色[blanch on pressure]
12、头发与指甲[hair and nail]
•头发（稀疏、浓密、秃头）的[hair (sparse, dense, bald)]
•头皮[scalp]
•粗（细）[coarse (fine)]
•密（疏）[thick (thin)]
•干性（油性）[dry (oily)]
•有（无）光泽的[lustrous (lusterless)]
•多（少、无）毛[hairy (oligotrichosis, hairless)]
•脱发（斑秃、全秃）[hair loss (alopecia areata, baldness)]
•眉毛（阴毛、腋毛）稀少（过多）[scant (excessive) eyebrows (public hair, axillary hair)]
•体毛（胡须）[body hair(beard) ]
•全身性多毛症[hypertrichosis universalis]
•毛发的性状和分布[quality and distribution of the hair]
•甲变形（匙状甲）[deformities of nail (spoonnail)]
•薄（脆）甲[thin (brittle) nail]
•甲脱落[ongchoptosis]
13、浅表淋巴结[superficial lymph nodes]
•浅表淋巴结未扪及[be no palpable superficial lymph nodes (…can not be palpated)]
•淋巴结肿大[enlarged lymph nodes (lymphnode enlargement)]
•部位[site]
▲全身（局部）[general (local)]
▲耳前（后）淋巴结[pre(post)-auricular nodes]
▲枕后淋巴结[occipital nodes]
▲颏下淋巴结[submental nodes]
▲下颌淋巴结[submaxillary nodes]
▲颈前（后）淋巴结[anterior (posterior) cervical nodes]
▲ 锁骨上淋巴结[supraclavicular nodes]
▲滑车上淋巴结[epitrochlear nodes]
▲腋窝上（内侧，前，后，外侧）淋巴结[axillary top (medial,anterior,posterior,lateral)]
▲腹股沟淋巴结（横组，纵组）[inguinal nodes (transverse group,longitudinal group) lymphnode]
•大小[size]
▲4×2cm大小[4 by 2 cm in diameter (size)]
▲米粒（豌豆，核桃，小指，拇指，拳头，手掌，鸡蛋）大小[size of a rice grain (pea,walnut,small,ringer,thumb,fist,palm,hen’s egg)]
▲针头大小[pinhead size]
▲苹果大小[size of an apple]
▲小孩头（成人大小）[size of a infant’s(man’s) head]
•形态[shape]
▲不规则[irregular]
▲结节（颗粒、纺锤）状的[tuberous (granular,spindle-shaped)]
▲光滑（粗糙）的[smooth (coarse)]
▲平坦（凹凸不平）的[flat (uneven)]
▲球（椭园，卵园，园）形的[globular (elliptical,oval,circular)]
•硬度和活动度[hardness and mobility]
▲硬（软）[hard (soft)]
▲石头（骨）样硬[of stone-like (bone-like)]
▲可活动（固定）的[movable (fixed)]
▲与周围组织（结构）固定[be fixed to the surrounding tissues (structures)]
▲压痛[tenderness]
▲融合（粘连）[fusion (adhesion)]
▲肿胀（疤痕）[swelling (fistula)]

既然是病历，肯定少不了问诊，一下是问诊常用句子的英汉版：

·Hello.may (can) I help you?[您好，我可以帮您吗？]
·What seems to be bothering you?[您觉得哪儿不舒服？]
·Do you have a record?[您有病历吗？]
·I`ll transfer you to the surgery department.[我给您转到外科去]
·what`s wrong with you?[您怎么了？]
·Sit down, please.[请坐]
·When did the symptom begin ?[症状是什么时候开始的？]
·Are you bring anything up when you cough?[咳嗽时有痰吗？]
·Have you had any chills (chest pain)?[您有发冷（胸痛）吗？]
·Have you ever coughed up blood[您咳血过吗？]
·All right. Let me examine you. Would you mind taking off your coat?[好吧。我给您检查一下，您不介意脱掉外衣吧？]
·Take a deep breath, please[请深呼吸]
·I`ll take a white blood count and give you a x-ray examination.[我将给您做白细胞计数和胸片检查]
·I`m sure it`s pneumonia. You should be admitted to the hospital.[我可以确定您得了肺炎，应当住院。]
·How long have you been like this?[这种症状有多久了？]
·When did you begin to notice these symptoms?[您什么时候发现这些症状的？]
·What`s the trouble?[怎么啦？]
·What`s your trouble?[你怎么啦？]
·What`s the trouble with you?[你哪儿不舒服]
·What`s troubling you?[你哪儿不舒服]
·What`s your complaint?[你哪儿不舒服]
·What`s bothering you?[你哪儿不舒服]
·What can I do for you?[你哪儿不舒服吗？]
·What`s up with you?[你生什么病了？]
·What`s the matter with you?[你哪儿不舒服？]
·Is there a sense of distension and numbness?[你有胀和麻木的感觉吗？]
·When did the trouble start?[什么时候开始不舒服？]
·When did the pain start?[什么时候开始痛的？]
·When did it happen?[什么时候发生的？]
·When did your diarrhea start?[你什么时候开始腹泻的？]
·What kind of pain do you feel?[你觉得怎么个痛法？]
·What kind of stool did you notce, watery or mucous?[你注意大便的样子了吗？是水样的还是粘液样？]
·What did you vomit, food or blood?[你吐的是什么？食物还是血？]
·What kind of treatment have you had?[你过去用什么方法治疗过？]
·What about your heart?[你的心脏怎么样？]
·What`s your stool like?[大便是什么样子？]
·Where is your pain?[你觉得哪儿痛？]
·Where does it hurt?[哪儿痛？]
·What`s your appetite?[你的胃口怎么样？]
·How`s your appetite those days?[近来食欲怎么样？]
·How long have you been feeling like this?[你有这样感觉多长时间了？]
·Have you been coughing and sneezing?[你是不是一直咳嗽和打喷嚏？]
·Have you got a high fever?[你发烧吗？]
·Any fever?[发烧吗？]
·Have you got any chronic disease before?[你以前有过慢性病吗？]
·Does it bleed often?[常出血吗？]
·Do you feel short of breath?[你觉得气急吗？]
·Do you feel pain after meals?[是饭后痛吗？]
·Do you feel abdominal pain when you go to the toilet?[你去厕所时感到腹痛吗？]
·Do you have a pain in your stomach?[你肚子痛吗？]
·Do you have a cough?[你咳嗽吗？]
·Do you remember how many times you went to the toilet?[你记得去过多少次厕所吗？]
·Did you receive any treatment before you came to the hospital?[来医院前你接受过治疗吗？]
·I`d like to listen to your chest.[我想听听你的胸部。]
·I`d like to run a few tests.[我想给你做些检查。]
·You must have a blood (sputum) test.[你需要验验血（痰）。]

I`ll run some tests on you.[我要给你做些化验。]
·That`s due to your heavy period.[这是因为你月经过多造成的。]
·I think it`s carcinoma of the breasts.[我认为是乳腺癌。]
·We`ll send her to the delivery room for further observation.[我们想把她送到产房进一步观察。]
·Do you see dimly from distance or close by?[您看远不清还是看近不清？]
·Do you see objects dimly?[您看东西模糊吗？]
·What kind of pain do you have?[怎么痛法？]
·Is there much secretion from your eyes?[眼里的分泌物多吗？]
·Does light affect your eyes?[您的眼睛怕光吗？]
·Do you see an object as if there were two that overlap?[您看东西有重影吗？]
·Do you see my hand moving?[您看见我的手在动吗？]
·Try not to blink.[不要眨眼。]
·Are you near-sighted or far-sighted?[您是近视眼还是远视眼？]
·Come back in a week for a re-examination of your eyes.[一周以后来复查您的眼睛。]
·I`ll send you some medicine (pill, ointment).[给你开些内服药（丸药，膏药）。]
·I`ll give you some tablets.[我给你一些药片。]
·I`ll make up a prescription for you.[我给你开一张药方]
·I`ll write out a prescription for you right now.[我马上给你开张药方。]
·I`ll give you a prescription. Take it to the chemist`s [我给你一张处方，到药房去配药。]
·I think you`d better take Chinese traditional medicine.[我认为你最好服用中药。]
·Take the medicine according to the instruction.[请按医嘱用药。]
·I`d like to put you on some medicine and have you come back in several days.[给我开点药，几天以后你再来。]
·One tablet each time, three times a day after meals.[每日3次，每次1片，饭后服。]
·Take one capsule every four hours.[每4小时服用一胶囊。]
·Take a dose three times a day.[每天服3次，每次一剂。]
·Put the ointment on the sore once a day.[把软膏涂在患处，每日1次。]
·Shake well before using it.[使用之前要摇匀。]
·The medicine will relieve your pain.[这种药会给你止痛。]
·This medicine can keep your fever down.[这种药可给你退烧。]
·This is for oral administration.[这是口服药物。]
·This lotion is for external use only.[这种洗剂只可外用。]
·You`re suffering from acute appendicitis and must have an operaton.[你得的是急性阑尾炎，要动手术。]
·I`m sorry to say you`ll have an immediate operation.[很遗憾，你得快动手术。]
·Your meals should be frequent but small in quantity.[应该少吃多餐。]
·Your meals should be light and digestible.[吃的东西要清淡容易消化。]
·You should take some more vitamines[你应该多吃些维生素。]
·You should go on a diet.[你应该节食。]
·You can`t touch anything sweet.[你一点甜食也吃不得]
·Fatty food will do you harm.[高脂肪食物对你有害处。]
·Avoid eating greasy food.[不要吃油腻食物。]
·Drink plenty of water.[要喝大量的水。]
·You are scheduled to have a GI and a GB test tomorrow morning.[您预定明天早上作胃肠检查和胆囊检查。]
·Please don`t eat or drink anything until the test is over. I`m sorry but you have to have an absolute empty stomach.[要检查结束之前请不要吃喝任何东西。我很抱歉，您得完全空着胃。]
·This test is done on a 24 hour basis from 6 in the morning until 6 in the following morning.[这个检查是以早晨六点到第二天早上六点的二十四个小时为单位进行的。]
·You may have something to drink whenever you wish.[你可以随意喝你想喝的东西。]
·Please use this container for your urine.[请将尿放进这个容器内。]
·Breathe in deeply. That`ll do.[深呼吸，好了。]
·Now take a breath.[现在吸气。]
·Now take a deep breath with your mouth open.[现在嘴张开作深呼吸。]
·Now turn around, please.[现在请转过去。]
·Take it easy and don`t move.[放松点，别动。]
·Show me exactly where it is.[请告诉我准确的地方。]
·Show me your tongue, please.[请把舌头伸出来。]
·Show me which one it is?[告诉我是哪个？]
·Show me where it hurts the most.[告诉我哪儿最疼。]
·You`d better have a chest X-ray.[你最好透视一下胸部。]
·Your tongue is rather coated.[你的舌苔比较厚。]
·Dull tongue with whitish and greasy coating.[舌质暗，苔白腻。]
·How do you feel now?[现在你觉得怎么样？]
·Where does it hurt?[哪儿痛？]
·Which of your arms is sore?[你哪个胳膊痛？]
·Do you feel weak?[你感到身体虚弱吗？]
·Do you have any pain in your belly?[你腹部痛吗？]
·Does it hurt here?[这儿痛吗？]
·You are scheduled to have an operation.[您要预定动手术。]
·First of all, we will prepare you by shaving.[首先，我们要给你备皮，做手术前的准备工作。]
·I will give you an NG tube right now.[我马上给你插鼻胃管。]
·Urinating after an operation is very hard.[手术后排尿很困难。]
·Did you pass any wind by rectum?[有气从肛门排出吗？]
·You can lie on your side more often.[您可以经常翻身。]
·You look a little better today.[今天看来你精神好一些。]
·You can get out of bed today.[你今天可以下床了。]
·Shall we limit the amount of visitors?[要不要限制访客的人数呢？]

支持一下，打出来好好看看，谢谢小月啦

好东东，值得看一下