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您現(xiàn)在的位置: 醫(yī)學全在線 > 醫(yī)學英語 > 英語教學 > 英文病歷 > 正文:簡明病歷書寫手冊第二章:主訴[Chief Complaint]
    

英語病歷書寫手冊第二章:主訴[Chief Complaint]

1、主訴的表示方法:癥狀+時間(Symptom+Time)
•癥狀+for+時間
如: [Chest pain for 2 hours] 胸痛2小時
•癥狀+of+時間
如: [Nausea and vomiting of three days` duration] 惡心嘔吐3天
•癥狀+時間+in duration
如: [Headache 1 month in duration] 頭痛1月
•時間+of+癥狀
如: [Two-day history of fever] 發(fā)熱2天
2、常見癥狀
• [Fever] 發(fā)熱
• [Pain] 疼痛
• [Edema] 水腫
• [Mucocutaneous hemorrhage (bleeding)] 皮膚粘膜出血
• [Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困難
• [Cough and expectoration (Sputum;Phlegm)] 咳嗽和咯痰
• [Hemoptysis] 咯血
• [Cyanosis] 紫紺
• [Palpitation] 心悸
• [Chest discomfort] 胸悶
• [Nausea (Retch;Dry Vomiting)and Vomiting] 惡心和嘔吐
• [Hematemesis (Vomiting of blood)] 嘔血
• [Hematochezia (Hemafecia)] 便血
• [Diarrhea] 腹瀉
• [Constipation (Obstipation)] 便秘
• [Vertigo (Giddiness; Dizziness)] 眩暈
• [Jaundice (Icterus)] 黃疸
• [Convulsion] 驚厥
• [Disturbance of consciousness] 意識障礙
• [Hematuria] 血尿
• [Frequent micturition,urgent micturition and dysuria] 尿頻,尿急和尿痛
• [Incontinence of urine] 尿失禁
• [Retention of urine] 尿潴留
(1)發(fā)熱的表示方法
• [Infective (Septic)fever] 感染性發(fā)熱
• [Non-infective (Aseptic)fever] 非感染性發(fā)熱
• [Dehydration (Inanition)fever] 脫水
• [Drug fever] 藥物熱
• [Functional hypothermia] 功能性低熱
• [Absorption fever] 吸收熱
• [Central fever] 中樞性發(fā)熱
• [Fever type] 熱型
▲ [Continuous fever] 稽留熱
▲ [Remittent fever] 馳張熱
▲ [Intermittent fever] 間歇熱
▲ [Undulant fever] 波狀熱
▲ [Recurrent fever] 回歸熱
▲ [Periodic fever] 周期熱
▲ [Irregular fever] 不規(guī)則熱
▲ [Ephemeral fever] 短暫熱
▲ [Double peaked fever] 雙峰熱
• [Fever of undetermined(unknown) origin, FUO] 不明原因發(fā)熱
• [Rigor (shivering;chill;shaking chill;ague)] 寒戰(zhàn)
• [Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒
• [Ultra-hyperpyrexia] 超高熱
• [Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高熱
• [Moderate fever] 中度發(fā)熱
• [Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低熱
• [Become feverish (Have a temperature)] 發(fā)熱
• [Crisis] 驟降
• [Lysis] 漸降
• [Typhoid fever] 傷寒
• [Rheumatic fever] 風濕熱
• [Cancerous fever] 癌性發(fā)熱
• [Fervescence period] 升熱期
• [Defervescence period] 退熱期
• [Persistent febrile period] 持續(xù)發(fā)熱期
(2)疼痛的表示方法
• [Backache (Back pain)] 背痛
• [Lumbago] 腰痛
• [Headache] 頭痛醫(yī)學.全.在線.網(wǎng).站.提供
▲ [Vasomotor headache] 血管舒縮性頭痛
▲[Post-traumatic headache] 創(chuàng)傷后頭痛
▲[Migraine headache] 偏頭痛
▲ [Cluster headache] 叢集性頭痛
• [Chest pain] 胸痛
• [Precardial pain] 心前區(qū)痛
• [Retrosternal pain] 胸骨后痛
• [Abdominal pain (Stomachache)] 腹痛
• [Acrodynia (pain in limbs)] 肢體痛
• [Arthrodynia (Arthralgia)] 關節(jié)痛
• [Dull pain] 鈍痛
• [Sharp pain] 銳痛
• [Twinge pain] 刺痛
• [Knife-like pain (Piercing pain)] 刀割(刺)樣痛
• [Aching pain] 酸痛
• [Burning pain] 燒灼痛
• [Colicky (Griping;cramp) pain] 絞痛
• [Colic] 絞痛
• [Bursting pain] 脹痛(撕裂痛)
• [Hunger pain] 饑餓痛
• [Tic pain] 抽搐
• [Bearing-down pain] 墜痛
• [Shock-like pain] 電擊樣痛
• [Jumping pain] 反跳痛
• [Tenderness pain] 觸痛(壓痛)
• [Girdle-like pain] 束帶樣痛
• [Wandering pain] 游走性痛
• [Throbbing pain] 搏動性痛
• [Radiating pain] 放射性痛
• [Cramping pain] 痙攣性痛
• [Boring pain] 鉆痛
• [Intense pain] 劇痛
• [Writhing pain] 痛得打滾
• [Dragging pain] 牽引痛
• [Labor pain] 陣痛
• [Cancerous pain] 癌性疼痛
• [Referred pain] 牽涉痛
• [Persistent pain (Unremitting pain)] 持續(xù)性痛
• [Constant pain] 經常性痛
• [Intermittent pain] 間歇性痛

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