英语病历书写模板汇总 |
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胃肠 Stomach & Bowels (1)当空腹时,他感觉胃里不舒服。 He has a certain disagreeable felling in the stomach when it is empty. 胃 胃不调 upset stomach 消化不良 have bad (impaired: defective) digestion; suffer from indigestion (dyspepsia) 胃有毛病 have a disordered stomach (stomach disorder); something is wrong with one's stomach. 因过食而伤胃 injure one's stomach by overeating oneself 觉食物积滞胃中 feel heavy on the stomach 食物不易消化lie (sit) heavy on one's stomach Ex1:自从那时起,消化便已失常。 Thereafter, the digestion was not really good. (2)曾有过一时性的恶心和呕吐,但并没有食欲不振或体重减少发生。 Transient nausea and vomiting was present, but no anorexia or weight loss occurred. 恶心 欲呕 feel nauseated 有晨吐 have morning sickness 夜吐(饭后恶心) nocturnal (postprandial) nausea 晕船(车) be sea (car) sick 有点恶心 have (experience) some nausea 严重的作呕 have considerable retching 里急后重时发生恶心和呕吐 have a spell of N & V while straining at stool 患食欲不振和恶心 be anorexic and nauseated 偶而恶心和呕吐 develop occasional nausea and vomiting 老是溢酸,感觉腹胀 burp all the time, feel bloated 吐出清净透明的胃容物 with vomiting of clear gastric contents 呕吐停了,消失了vomiting stopped (ceased), cleared 止吐 settle the stomach 打噎 belch (eruct; eructate) Ex1:这病人恶心,曾呕吐了含有胆汁液体数次。 The patient developed nausea and vomited bilestained fluid on several occasions. Ex2:当要呕吐时,他发觉有严重的腹上部痛和剧烈的头痛。 With the advent of vomiting, he noted severe epigastric pain as well as severe headache. (3)在第2天中午,她开始呕吐,随后呕吐胆汁质物。 At noon on the following day she stared vomiting food, which was followed by bilestained material. 在病发时呕吐2次 vomit twice at the onset 极度反胃 regurgitate food violently Ex1:一小时后,他吐出不含血液的水质样东西。 One hour later, he vomited watery material containing no blood. Ex2:有时这病人在发作最厉害时,呕吐1、2次。 Sometimes the patient vomited once or twice at the height of the attack. 呕吐物 Ex1:昨天早晨的呕吐物,被形容为含有未消化的食物和绿水,无血。 The vomitus of yesterday morning was described as containing indigested food and greenish water with no evidence of blood. Ex2:最初的呕吐物是透明的,但据说住院治疗之前的呕吐物,带有褐色。 The vomitus was initially clear but just before hospitalization was said to brownish. (4)他开始有多次、带泡沫和臭味的大便。 He began to have frequent, frothy, foulsmelling stools. 大便 解大便 open (relax; evacuate) the bowel; have a passage 有便意 have a call of nature 有1次(2次)大便 have a motion (two motions) 没有大便 be constipated 平均每天大便12次 averaged 12 stools daily 发觉粪便中有很多血 noticed gross blood in one's stools 开始一天解8次松的多脂粪便 began to pass 8 loose greasy stools per day 大便增加到一天4—5次 stools increased in number to 4 or 5 daily 更换尿布时有些粪便 have some stool in each diaper change Ex1:大便次数减少了,但他仍然每天继续有2—3次大量的稀大便。 The stools became fewer in number but he still continued to have 2—3 large loose stools daily. Ex2:住院前2个月,她发觉黑色大便,但却把它忽略过去了。 Two months before admission she had noticed black stools but she disregarded them. 大便检查 种类 ordinary, dry, hard, loose(soft), large, watery(liquid), formed, formless, frothy, mucous, bloody, ricewater, peasoup, tarry 臭味 odorless, extremely foul, sour, putrid, less offensive in odor, offensive but no excessively foul 颜色 black, tarry, brownishblack, brown, red, green, yellow, lightbrown, greywhite (claycolored) Ex1:大便的粗细和硬度正常,且从未呈黑色。 The stools were of normal caliber and consistency and have never been black. Ex2:大便颜色很淡,并且软如泥。 Stools were very light in color and of mushy consistence. (5)他诉说间歇性腹泻与便秘交替发生。 He complained of intermittent diarrhea alternating with constipation. 便秘 便秘 suffer from constipation 惯性便秘 habitual constipation 时常便秘 be always constipated 有便秘倾向 have a tendency to be constipated 只有灌肠才能缓和严重的便秘 one's severe constipation was relieved only by enemas Ex1:便秘很难治,他以前常乞灵于泻药。 The constipation was very obstinate (stubborn) and he resorted to the frequent use of cathartics. Ex2:她的便秘逐渐严重起来,同时发觉到粪便直径变细。 She became progressively more constipated and noted a narrowing in the caliber of the stools.腹泻 晨泻,水泻,粘液性腹泻,慢性腹泻 diarrhea (morning, watery, mucous, dysenteric, chronic) 腹泻 diarrhea (轻症 mild,拖延的 protracted, 无法控制的 uncontrolled, 难医的intractable) 患腹泻 suffer from diarrhea; have (an attack of ) diarrhea; have loose bowels 短期的腹泻发生了 a brief episode of diarrhea occurred 开始泻腹(自然消失,于两天后消失) diarrhea commenced (spontaneously disappeared, cleared after 2 days) 偶而泻肚子 have occasional diarrhea 腹泻厉害,在3—7次之间 diarrhea varied in severity from 3 to 7 B.M. 不得不服药 be obliged to take physics 腹泻未因吃脱脂牛奶而转佳 received skim milk without any improvement in the diarrhea 用泻药 use a purgative Ex1:他患腹泻,每天有8—10次带有粘液,脓和鲜红色血的大便。 He developed diarrhea with the daily passage of 8—10 stools containing mucous, pus, and bright red blood. Ex2:以前他患过同样的腹泻,但从来没有这么严重过。 He previously had similar attacks of diarrhea but they were never so severe. 排尿生殖器(1)他诉说,在两侧鼠蹊部和睾丸有拉痛,且有夜尿,小便时有灼热感,间或放红色的尿。 He complained of a drawing pain in both groins and testicles, nocturia, burning on urination and the intermittent voiding of red-colored urine. 尿 种类 colorless, clear, transparent, translucent(semitransparent), opaque, milky(opalescent) cloudy(turbid), orange, greenish, dirty blue, green, yellow(amber; straw), red, bright red, brown yellow, dark-brown, brown-dark, light brown, pale yellow, faint pale, clay-colored, patty-colored 排便 micturate; make(pass) water; void; piss 一夜有2次小便 have nocturia twice nightly (a night) 这次住院时解出一个结石 pass a stone on this admission 小便浑浊 one's urine is thick(colored) 解出极浑浊,乳白色的尿 the passage of highly turbid, milky urine 频尿 frequent urination(micturition) 无法忍受的频尿 intolerable frequency of urination 终末性血尿 terminal hematuria 终末尿带有几滴血 urine terminates with a few drops of blood 排尿痛 micturition pain 解尿时左腰疼痛 have pain in the left loin on micturition 小便流势良好 void with a good stream 尿流细小 small u
呼吸Resp., 咳嗽Cough, 痰Sputum (1)他诉说被呼吸困难苦恼了好多天。 He complains of difficulty of breathing, which annoyed him for several days. 呼吸 呼吸困难 breathe hard (with difficulty) ; have difficulty in breathing ( respiration) 呼吸困难 dyspnea (夜间性 nocturnal, 发作性paroxysmal) 安静时(运动性)呼吸困难 dyspnea at rest (on exertion) 常发生发作性夜间呼吸困难 frequent episodes of paroxysmal nocturnal dyspnea 呼吸困难突然厉害起来 have sudden increase in dyspnea 患轻微的运动性呼吸困难 have some mild exertional dyspnea 患急性呼吸困难 have an acute attack of dyspnea 无呼吸困难 have no respiratory embarrassment 偶有心悸 have occasional palpitations 心悸反复发生 have recurrent episodes of palpations Ex1:第2天早晨,病人呼吸变为非常困难和衰弱。 The next morning the patient became extremely dyspneic and weak. Ex2:走快或上楼梯时,他总是气促的。 He always becomes shortwinded when walking hastily or going up stairs. (2)这个病人常常咳嗽,并且吐出灰色的臭痰。 The patient coughs very often and expectorates foulsmelling grayish sputum. 咳嗽 种类 short, sharp, small, dry(hasty), moist, constant, painful, irritable, spasmodic, wheezing, distressed, rasping 咳个不停 have a fit of coughing; cough oneself into a fit (fits) 苦咳个不停 have a hard (racking; convulsive) cough 患4天干燥发作性咳嗽 experience a 4day episode of dry paroxysmal cough. 2岁时开始有间歇性烦咳 intermittent hacking cough started at 2 years old 咳嗽减少了 one's cough diminished 发生轻度无痰的干咳 develop slight nonproductive cough 有点(很多)咯血 have minimal (massive) hemoptysis. 咯出一点血 cough (expectorate; spit) up (out) a little blood 开始咯出黑血斑点 began coughing op flecks of dark blood 呕血 vomit blood Ex1:他偶而咳嗽,但不曾感觉胸部痛、发烧或体重减轻。 He coughed occasionally, but he has never experienced pain in the thorax, fever, or loss of weight. Ex2:最近6个月,他的咳嗽一直带有轻微咯血。 For the last 6 months, he has been coughing with slight hemoptysis. 痰 种类 thin, thick, fetid, serous, frothy, tenacious, viscous, mucous( mucoid), mucopurulent, transparent, seropurulent, rusty 中等量(多量、大量)带有灰白色痰的咳嗽 moderate amounts (a great deal, large quantities) of grayishwhite sputum 痰涌上咽喉,有酸味 phlegm wells up in the throat and tastes sour 痰堵住嗓子了 phlegm blocked the windpipe 半杯黄色痰 one half cup of yellowish sputum 吐脓性,偶而带血的痰 produce purulent, occasionally bloodtinged sputum 开始有点咳嗽,并且有约3公撮的血痰 began to have some cough and produced about 3 ml. of bloody sputum. 一点也咳不出痰 do not raise any phlegm at all 咳痰停止了 expectoration ceased Ex1:他开始有少量带血丝的痰。 He began to expectorate small amounts of bloodstreaked sputum. Ex2:他的咳嗽已经不像以前那样厉害,痰里也不再有血斑了。 His cough was not so severe as it had been and sputum was no longer flecked with blood. 神经精神系统 Neuropsychiatric (1)他数星期来,有好几次在眩晕前,意识突然发生变化。 He had several sudden alterations in consciousness preceded by dizziness for several weeks. 神经症状 一般用语 vertigo, dizziness, dizzy spell, syncope, fainting, sleepy, drowsy, lethargic, insomnia, hiccough, convulsion, seizure, trembling, involuntary movement, numbness, weakness, incoordination, clumsiness of motion, tingling, unsteadiness in walking, difficulty in walking, paresthesia, anesthesia, paralysis, myalgia, thick speech, aphonia ex1:他发觉,说话障碍逐渐厉害起来。 He noted a progressive speech impediment. ex2:他不能用病侧脚尖站着。 He was unable to stand on tiptoe on the affected limb. (2)他的情绪容易突变,且会无缘无故地愠怒和哭泣。 He is liable to sudden changes of mood and would sulk and cry for no apparent reason. 抑郁 一般用语 despondent, gloomy, worried, disgusted, discouraged, scared, fearful, low, afraid, angry, blue ; cheerful, optimistic, pessimistic, satisfied, stable, fluctuating, hilarious 喜欢小题大做的 fussy 好管闲事的 noisy 吹毛求疵的 fault finding 自负的 conceited 很势利的 snobbish 自私的 selfish 吝啬的 stingy 气量大的 broad minded 慷慨的 generous 好心的 kind hearted 心情变幻不定而抑郁的 be moody and depressed 患有极痛苦的忧虑 have an attack of excruciating anxiety ex1:His mood was appropriate. ex2:His mood was mainly euphoric and expansive. 思考能力 一般用语 think less clearly, decreased speed of thinking, decreased clarity of thought, flight of ideas, loss of mental vigor , mental apathy 再也不能集中心力 can no longer concentrate 发觉集中力减退 noted waning powers of concentration ex1:她发觉在读习和写作时,注意力有点不易集中。 She noted only slight difficulty in concentrating while reading and writing. (3)他迷妄,有生动的幻觉,并且不能说出连贯的病历。 He was deluded, vividly hallucinated, and unable to give any coherent history. 精神异常 一般用语 hallucination, delusion of persecution(被害妄想), mental confusion, disorientation, mental aberration, negativism, loss of memory, amnesia, mutism, etc. 老是发出痴呆、不适当的笑声 frequently exhibit silly inappropriate laughter 对其他小孩残酷无情 behave brutally toward other children 变为难于驾御 become unmanageable 发觉个性显著变化 a definite personality change is noted 精神失常逐渐厉害起来 have gradually progressive mental deterioration. 发觉记性障碍有2个月 noted memory impairment for 2 months. (4)她显示出心情、情绪反常的显著倾向。 She manifested a marked tendency toward destructiveness and disturbance of mood and affect. 性癖异常 一般用语 emotional instability, tendency to worry, hot temper, temper outbursts, irritable, shy, fussy, quarrelsome 情绪非常窘迫 be in severe increasing emotional lability 心神不安宁,坐立不安 be restless and fidgety 动辄生气 be easily moved to anger 脾气暴躁 have temper tantrums 深怀自卑感 harborn deep feelings of inferiority ex1:病人的健康状态良好,情绪似使正常。 The patient is in good condition and seems to be emotionally undisturbed. ex2:他老是神经过敏,自从心悸发生后更加厉害。 He was always a 'nervous' person but more so since the onset of palpitation.
食欲 Appetite 体重 Weight 他说他胃口一直很好,什么东西都能吃。 He stated that he had always had a good stomach and could eat anything. 食欲良好 过食 eat too much (to excess ; heavily); overeat; be intemperate in eating 吃得多 (胃口大开地吃)eat profusely (with a good appetite) 保持良好食欲 retained an excellent appetite 食欲增进 one's appetite improved 食欲有节制(食欲旺盛,贪食不饱) have a moderate (good, enormous) appetite 无食欲障碍 one's appetite is undisturbed 食不过饱的人 a moderate (spare; light) eater 过饱的人 a heavy (great; hard) eater 食量 capacity for eating ex1:他的食欲良好,但他平常的吃食习惯,由于口里伤处而中断。 His appetite was good, but the sore place in his mouth interrupted his usual eating habit. ex2:他对食物有无法控制的喜好,用膳时喝很多水。 He had an uncontrollable mania for food, drinking water freely with the meals. 无食欲 无食欲 have no (little) appetite (for food); lose (have no) relish for one's food; loss (lack) of appetite; loss of interest in food 发觉(有点)食欲不振 noted (minimal) anorexia 食欲不定(无食欲障碍) one's appetite is variable (undisturbed) 食欲反复无常 have a capricious appetite 食欲不佳 have a poor (feeble; weak; delicate) appetite 胃口变得更加不好 became more anorexic 失去平常的食欲 lose one's usual appetite 食欲减退 appetite decreases (reduces; declines; falls off) 吃得少 eat poorly (sparingly) ;take little food; poor food intake 不想吃 be disinclined to eat 取食不规则 eat irregularly 停吃 cease eating 促进食欲 improve (stimulate; sharpen; whet) the appetite ex1:他无胃口,只吃了一点点东西。 He had no appetite and only picked at the food. ex2:他的胃口不如以前,甚至以前喜欢吃的也不例外。 Meals and drinks taste no more as before, and he is indifferent even to his favorite food. ex1:他整天没有吃什么,只吃几口稀饭。 He eats nothing for a whole day, but he takes some mouthfuls of rice gruel. ex2:他从前天中午起,就没有吃东西。 He has tasted no food since noon the day before yesterday. (2)他诉说非常口渴,但一点食欲也没有。 He complains of his thirst hard to release, while he has absolutely no appetite. 口渴 口渴 be (feel) thirsty 口一直很渴 continue to have excessive thirst 喝大量的水 drink water generously 对碳酸饮料发生不寻常的爱好 develop an unusual craving for carbonated beverages 要~少喝茶水 be advised to decrease one's tea drinking (3)食欲正常,但体重却在一年之内减轻了4公斤。 In spite of the normal appetite, he lost 4 kg. in weight over a period of one year. 体重减轻 住院时体重 admission weight 最高(最低)体重 maximal (minimal) weight 体重减少,但未知多少 weight loss of undetermined amount 通常在夏季体重减轻 usually lose weight in the summer months 体重以惊人的速度减少 lose weight with alarming speed 体重始终一样 weight remained stationary (steady) 体重不变 weight is stable (unchanged) 体重维持不变 weight is well maintained 体重老是50公斤 one's weight is constant (maintained) at 50 kg. 虽然食量增加,体重却减轻了6公斤 lost 6 kg. in spite of increased intake of food ex1: 他在上2个月内,体重减轻了8公斤。 He developed weight loss totalling 8 kg. in the previous 2 months. ex2: 他的胃口变得很大,食物热量增加2倍,但体重却减轻了10公斤。 His appetite became ravenous and his caloric intake doubled, yet he lost 10 kg. |
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