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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 |
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| 来源：本站原创 更新：2008-5-2 医学论坛 | |||||
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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.]医学.全在.线www.med126.com •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)] |
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