2024年3月9日发(作者：)

英文病历全攻略

一、主要调查项目：

1.主诉chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight,

stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders,

respiration, shortness of breath, bleeding or discharge, etc.

2.现症历present illness：onset(date, mode), duration before present entry, exciting cause and

environmental influences, prodromal symptoms, general symptoms, course or progress( location,

duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating

factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination,

menstruation, etc.

3.既往历past history：

1)former places of residence, previous stage of health( 健壮的robust，纤弱的delicate),

experience with similar disease, immunity to infectious disease

2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性

感冒influenza, 猩红热scarlet fever, 白喉diphtheria，伤寒typhoid fever, 支气管炎bronchitis,

肺炎pneumonia，脑炎encephalitis,脑膜炎meningitis，破伤风tetanus,小儿麻痹poliomyelitis,

赤痢dysentery，霍乱cholera, 胸膜炎pleurisy,天花small-pox，疟疾malaria,结核病tuberculosis，

黄疸病jaundice，过敏性反应allergy,etc

3)venereal disease：specific symptoms, signs, and the disease by name, treatment.

4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name

of hospital , physician, complications, bleeding tendency)

4.家族历family history：family tendency, presence of hereditary disorders, cancer, tuberculosis,

mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular

accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals,

relationship of patient’s childhood and adult life, age, health condition, and cause of death of

parents, grandparents, self , spouse, siblings , or relatives.

5.个人历personal history：

1)Social history：fears, metal status, education, financial condition, number of dependents, family

harmony or fractious , hygienic condition at home

2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spouse and children ,

cause and age at time of death, number of children , pregnancies, 流产次数miscarriages, 死产数

stillbirths

3)occupational history：duration of employment, past work, exact nature of work, exposure to

occupational hazards, whether work is satisfactory or not.

4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity

of eating , bowel movements, sleep, exercise, interests, etc.

6.系统检查system review：

1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.

2)Skin：荨麻疹hives, rash, eczema

3)Head：trauma, headache, loss of hair

4)Eyes：vision, pain glasses diplopia.

5)Ears：pain, discharge, deafness, tinnitus.

6)Nose：obstruction, discharge, epistaxis, rhinitis.

7)Mouth：teeth, lips, gums, tongue, disturbance in taste.

8)Throat.：sore throat, tonsillitis, 脓性扁桃腺炎quinsy, dysphagia

9)Neck：adenitis, goiter , rigidity

10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough ,

hemoptysis , seasonal cold, expectoration.

11)Gastrointestinal：appetite, nausea, vomiting, distress(before or after meals), melena, colic,

jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement ,

heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food

12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume,

enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous

patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history,

catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal,

menopause) leucorrhea, associated headache

13)Neuromuscular：神经过敏nervousness, emotional stress, weakness, muscle or joint pains,

convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.

二、病历与时态

1．现症历(present illness)：

1)A.现在式：表示一般的真理、职业、人格、习惯和现在的事实、动作或状态。

例1：Sedentary habits often interfere with health

例2：He is mentally deranged and disoriented as to time, place, and person

例3：He gets up at 6 every morning.

B.现在进行式（Be+ pres. p.）表示现在某动作正在进行中。

例1：Both his parents are still living and well.

例2：The patients is getting worse and worse.

例3：The patients is progressively doing well.

C.表「经常的习惯」也用进行式，通常与always, constantly等副词连用。

例1：He is always taking a nap in class.

例2：He is constantly forgetting peoples’ names.

例3：He is for ever complaining of headaches.

D.通常不用进行式的动词。

a)不随意动词( Verbs of involuntary actions)：

-知觉( perception)：feel, hear, notice, see, smell等。

例1：Whenever he has a cold, he can neither taste nor smell.

-知识(knowledge)：believe, (dis)agree, doubt, find, forget, know, mind, remember, think,

understand等。

例1：She does not remember specific scratches which might have preceded the present lesions.

-感情( emotion)：desire, despise, disgust, fear, hate, hope, (dis)like, love, prefer, want等。

例1：He likes lobster, but it disagrees with him.

b)表示继续状态的动词( Verbs of continuous state)：表示存在、所有等动

词：appear, be, belong, consist, flow, have, hold, live, look, possess, resemble, seem等。

例1：Her fingers and hands are stiff and cyanotic.

例2：He has no discomfort and eats well.

2)A.现在完成式( Have+ p.p)

a)表示动作的完了(completion of an action)或其结果的现在状态(present state of things)：

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