英文病历书写格式及详解

英文病历常用表述方式 

Terminologies in Medical Records 

1. 症状发作

Complain of/have a feeling (sensation) of/suffer from/have an attack of/have (fell)/begin to fell 

2. 疾病诱因

• 无诱因with no inducing factors
• 无明显诱因 under no obvious predisposing causes/without apparent inducement
• 活动时呼吸困难 dyspnea on exertion
• 与……有关 be associated with/have(make) relation to
• 与……无关 have (make) no relation to
• 伴发 be accompanied by
• 感冒一周后 after getting (catching) common cold for one week

3. 起病方式

• 突发胸痛 an explosive onset of chest pain
• 急性腹痛 acute abdominal pain
• 持续性胸痛 chest pain continually
• 反复胸闷心悸 recurrent (bouts of) chest discomfort and palpitation
• 频发胸痛 frequent episodes of chest pain
• 发作性呼吸困难 paroxysmal short of breath
• 慢性低热 chronic lower fever
• 突然起病伴高热 the onset was sudden with high fever
• 因……而突然发作 the attack is precipitated by
• 很快发生 occur rapidly
• 偶尔 occasionally, sporadically, accidentally
• 逐渐出现咳嗽咳痰 gradual onset of cough and sputum
• 一过性发作 transitory attack
• 频繁 frequently
• 持续性（间歇性） persistent (intermittent) 

4. 病情变化描述

• 好转 fell better than before; be better; take a favorable turn; improve; turn for the better
• 症状减轻 alleviate; reduce; palliate; diminish
• 症状消失 relieve; disappear; regress; clear up; vanish; dissolve
• 症状加重 be (become, get) worse; worsen; take a turn for the worse; be aggravated; increase in severity; take a bad turn
• 无变化 be alike; be similar; continue without change; be identical; resemble
• 体温/血压升降
• 法升至 rise (go up) to/ be elevated to
• 已升至 have risen (gone up) to
• 已降至 have gone down (dropped) to
• 骤降/升 sudden drop/elevation
• 渐降/升 fall/elevate gradually
• 降至正常 drop/was reduced to normal
• 回复到正常 return/revert to normal
• 维持在……水平 maintain at a level of
• 稳定在……stabilize at
• 不超过 do not exceed/go up over
• 在…..之间波动 fluctuate/vary between…and…

5. 时间

• 持续 last for/have continued for
• 超过/不到 more than/less than
• 多在……时发生 usually in the morning
• 2周未发作过 be free of onsets/attacks for 2 weeks

6. 严重程度

轻度/中度/重度 mild (slight)/moderate/severe (serious)

7. 其他

• 部位

Be located/situated in/over 位于…

There is localized pain in…疼痛位于…

Near…在…附件

Be localized to/in/over…局限于

Be limited/confined to 局限于

At the apex心尖部（表示小的部位/点可用 at）

In the upper abdomen 上腹部（表示大的部位可用in）

On/beneath the left lower limb 在左下肢（表示皮肤表面上/下的病变可用on）

Over the right lung 在右肺（表示正上方的可用over）

Above/below the mouth 嘴上/下方（表示高低/上下的位置关系）

Under the skin of the left breast 左乳皮下

• 转移到 shift (migrate) to…
• （疼痛）放射到 radiate/travel/go/refer to
• 从…放射到…radiate from…to…
• 耳鼻咽喉及口腔

耳痛 otalgia /pain of ears

耳鸣 tinnitus/ ears ring/a buzzing in the ears

耳聋 deafness/loss in hearing

鼻塞 nasal obstruction

打喷嚏和流鼻涕 sneezing and nasal discharge

水样鼻涕 watery rhinorrhea

鼻出血 nosebleed

咽喉痛 sore throat

吞咽困难 difficult in swallowing

流涎多 have excessive salvation

• 眼科及牙科

眼睑水肿 eyelid edema

眼痛 pain in the eyes

视疲劳 asthenopia (visional tired)

视力减退 hypopsia (diminution of vision)

视力模糊 indistinct vision

失明 loss of vision

牙痛 pain of tooth/odontalgia

牙龈出血 gingival bleeding

牙龈增生/萎缩 gingival hypertrophy/atrophy

• 妇产科

经量少 mild menses

月经过少 hypomenorrhea

阴道出血 vaginal bleeding

月经不规则 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

绝经 amenorrhea

停经 menopause

经期痛 pain during the flow

预产期 expected date of confinement

羊水过多（少） polyhydramnios/oligohydramnios

月经失调 menstrual disorder

经期水肿 menstrual edema

性欲减退 decreased libido

产程 stage of labor

产程延长 prolonged labor

产前出血 antepartum hemorrhage

产前子痫 prenatal eclampsia

产前检查 prenatal examination

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

• 一般情况

一般情况尚可/差 general condition is fair/bad

纳差 have a poor appetite

多食eat too much/overeat/eat heavily

少食 eat poorly/take little food

食欲减退 appetite decreases

口渴 feel thirsty

多饮 drink water generously

体重增加 gain in weight

体重增加…公斤 a…kilograms weight gain/gain…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

睡眠过度 hypersomnia

嗜睡somnolence/be fond of sleep

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

每日大便2次 have two stools daily

便秘/腹泻 constipation/diarrhea

排尿困难 difficulty in micturition

尿频/尿急 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

精神状态正常 orthophrenia/mental state is good

精神不振 lassitude

精神紧张/抑郁 mental stress/depression

病历内容 Contents of Medical Records

既往史、系统回顾和个人史

Past history, system review and personal history

1. 既往史 past history
2. 
   

• 无药物（食物）过敏史No past history of allergy to drugs(food)
• 有过敏史have allergic history of
• 有肺结核接触史 there was contact history of lung tuberculosis
• 健康状况佳（差）health state was good (bad)
• 既往体健 be well (healthy) before
• 不详 not in detail (not quite clear)
• 否认既往心、肺疾病史 deny any history of prior heart and lung disease
• 10年前曾患过…suffer from…10 years ago
• 外伤史 trauma history
• 预防接种史 history of preventive inoculation

2. 系统回顾 system review

• 循环系统：气短、心悸、胸痛、咳嗽、咯血、水肿、晕厥

Circulatory system: short of breath, palpitation, chest pain, cough, hemoptysis, edema, syncope

• 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 sweating, fever

• 消化系统：嗳气、发酸、腹胀、腹痛、腹泻、恶心和呕吐

Alimentary system: belching, sour regurgitation, abdominal distension, abdominal 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 urgency of micturition, painful micturition, abdominal pain, edema

• 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 sweating, polydipsia, edema, hand tremble, wasting and obesity

• 造血系统：乏力、头晕、心悸、出血

Hematopoietic system: fatigue, dizziness, palpitation, bleeding

• 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, and 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……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)
• 从事…职业be engaged in
• 卫生习惯和嗜好health habit and special addiction
• 不洁性行为史history of unclean coitus
• 不吸烟 no smoking(not a smoker)
• 吸烟10年，每天1包have smoked one packages of cigarette a day for 10 years
• 戒烟give up (stop) smoking
• 不饮酒 no alcohol use
• 偶尔饮酒 drink little liquor occasionally
• 大量饮酒 drink heavily (too much)
• 偏食 food preference
• 无偏食 no likes or dislikes in food
• 
  

4. 月经史menstrual history

•  初潮年龄age of menarche
• 月经周期menstrual cycle
• 经期menstrual period
• 末次月经时间last menstrual period(LMP)
• 月经正常eumenorrhea (regular menses)
• 闭经年龄 age of amenorrhea
• 月经过多 
• menorrhagia(hypermenorrhea,meno-metrorrhagia)
• 月经过少hypomenorrhea
• 月经过频 polymenorrhea
• 痛经 dysmenorrhea(pain during the flow)
• 月经不调 menoxenia(irregular menses, menstrualdisorder)
• 白带过多 profuse leukorrhea
• 经前疼痛（水肿）premenstrual pain (edema)
• 经量少/中/大
• mild/moderate/heavymenstrual blood
• 停经年龄pass the menopause at age… 

5. 婚姻史marital history

• 未婚/已婚single/married
• 结婚年龄age of wedding
• 配偶健康状况health status of partner(spouse)
•  近亲/非近亲结婚

  consanguineous/nonconsanguineous marriage

6. 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

 ·     流产 abortion/miscarriage

 ·     人工/自然流产次数 times of induced/spontaneous abortion/miscarriage

 ·   死胎dead fetus

 ·   早产premature birth

 ·   足月产 term labor

 ·     自然分娩 be delivered normally and spontaneously(spontaneous labor)

 ·   子女数number of children

 ·     产前/后子痫antepartum/postpartum eclampsia

 ·   母乳/人工喂养breast/artificial feeding

 ·     发育正常 normal development

 ·     发育异常/畸形/缺陷 developmental anomaly/deformity /defect

 ·   发育迟缓hypoevolutism

7. 家族史 family history

 ·   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