常用的临床医学术语.doc

,简明病历书写手册（英汉对照） 郭航远 编著目 录 第一章病人身份第二章主诉第三章现病史第四章过去史、系统回统和个人史第五章月经、婚姻、生育史和家族史第六章体检（一般项目）第七章体检（头颈部）第八章体检（胸腹部）第九章体检（神经、骨骼和肌肉）第十章体检（泌尿生殖道与其他）第十一章标准化病人体检项目第十二章实验室检查第十三章辅助检查第十四章诊断（疾病名称）第十五章常用医嘱术语第十六章常用药物及中草药第十七章住院文书格式第十八章附录 附1、常用解剖术语 附2、医学英语常用前后缀 附3、医学英语的特征 附4、医学英语常用短语 附5、英语问诊常用句子 附6、医学英语缩写一览表 附7、医院日常用品和设备 附8、医学院和医院相关名称 前 言随着我国加入WTO，医疗体制发生了革命性的改变。随着改革开放的深入，外国投资和管理的医院将不断涌现，中外医学交流也日趋频繁，出国学习、进修和援外医疗队的医务人员逐年增多，这就要求医生具有正确书写英文病历的能力。目前，国内供临床医生完成英文病历的参考书很少。签于此，编著者根据美国罗马琳达大学的病历书写要求，结合十余年的国内外工作经验（编者所在的邵逸夫医院是一所由美国专家管理的、与国际接轨的新型综合性医院，有十余年的英文病历书写实践），并参阅一些国内外的相关文献，编写了本手册。本手册按病历书写的顺序进行编写，采用英中对照写法，内容详尽，条理清晰，形式新颖，适用于临床医生、出国人员、实习生和医学院校的学生。在本手册的编写过程中，得到了美国罗马琳达大学医学院和日本福井大学医学院和邵逸夫医院领导的关心和支持。谨以此书献给我的老师、同事、朋友和家人。 第一章 病人身份Identification Name 姓名 Sex 性别 Age 年龄 Occupation 职业 Date of birth 出生日期 Marriage （Marital status） 婚姻 Race 民族 Place of birth (Birth place) 籍贯 Identification No.(code of ID card No.) 身份证号码 Department of work and TEL. No. (Unit and Business phone No.) 工作单位及电话 Home address and phone No. 家庭住址及电话 Post code 邮政编码 Person to notify (Correspondent) and phone No. 联系人及电话 Source (Complainer;offerer;supplier;provider) of history 病史陈术者 Reliability of history 病史可靠程试 Medical security (Type of payment) 医疗费用 Type of admission (Patient condition) 住院类别（入院时病情） Medical record No. 病历号 Clinic diagnosis 门诊诊断 Date of admission (admission date) 入院日期 Date of record 记录日期1、年龄的表示方法（以36岁为例）36 years old (y/o)Age 3636 year-oldThe age of 3636 years of age2、性别的表示方法 Male, 男性 Female, 女性3、职业的表示方法工人Worker 退休工作Retired worker农民Farmer (peasant) 干部Leader (cadre)行政人员administrative personnel (staff)职员staff member 商人Trader (Businessman)教师Teacher 学生Student 医生Doctor药剂师Pharmacist护士Nurse 军人Soldier 警察Policeman工程师Engineer 技术员Technician 家政人员Housekeeper家庭主妇Housewife 营业员Assistant服务员Attendant售票员Conductor 4、民族的表示方法 汉Han 回Hui 蒙Meng 藏Tibetan朝鲜Korean美国人American 日本人Japanese 英国人Britisher5、医疗费用的表示方法 Self pay (Individual medical care) 自费 Government insruance (Public medical care) 公费 Insurance 保险 Local insurance 本地医保 Non-local in surance 外地医保 Labor protestion care 劳保6、婚姻状况的表示方法 Married 已婚 Single (Unmarried) 未婚 Diverced 离婚 Widow 寡妇 Widower 鳏夫7、病史可靠程度的表示方法 Reliable 可靠 Unreliable 不可靠 Not entirely 不完全可靠 Unobtainable 无法获得8、住址的表示方法NO.3,Qing Chun Road East,Hangzhou, Zhejiang 浙江省杭州市庆春东路3号XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province. 浙江省诸暨市（县）城关镇新东村9、病史陈述者的表示方法 Patient himself (herself) 患者本人 Her husband 患者的丈夫 His wife 患者的妻子 Patients colleague 患者的同事 Patients neighbor 患者的邻居 Patients Kin (Mother; Son; daughter;brother;Sister) 患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹) Taximan 出租车司机 Traffic police 交通警察10、日期的表示方法2002年10月1日10-1-2002(10/1/2002; Oct.1,2002; Oct.lst,2002)(美国)2002年10月1日1-10-2002(1/10/2002; 1 Oct.,2002; 1st of Oct.,2002) (英国)11、住院类别的表示方法 Emergent (Emergency call) 急诊 Urgent 危重 Elective (General) 一般（普通）12、入院时病情的表示方法 Stable 稳定 Unstable 不稳定 Relative stable 相对稳定 Critical (Imminent) 危重 Fair (General) 一般第二章 主诉Chief Complaint1、主诉的表示方法：症状+时间（Symptom+Time）症状+for+时间如： Chest pain for 2 hours 胸痛2小时症状+of+时间如： Nausea and vomiting of three days duration 恶心呕吐3天症状+时间+in duration如： Headache 1 month in duration 头痛1月时间+of+症状如： Two-day history of fever 发热2天2、常见症状 Fever 发热 Pain 疼痛 Edema 水肿 Mucocutaneous hemorrhage (bleeding) 皮肤粘膜出血 Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath) 呼吸困难 Cough and expectoration (Sputum;Phlegm) 咳嗽和咯痰 Hemoptysis 咯血 Cyanosis 紫绀 Palpitation 心悸 Chest discomfort 胸闷 Nausea (Retch;Dry Vomiting)and Vomiting 恶心和呕吐 Hematemesis (Vomiting of blood) 呕血 Hematochezia (Hemafecia) 便血 Diarrhea 腹泻 Constipation (Obstipation) 便秘 Vertigo (Giddiness; Dizziness) 眩晕 Jaundice (Icterus) 黄疸 Convulsion 惊厥 Disturbance of consciousness 意识障碍 Hematuria 血尿 Frequent micturition,urgent micturition and dysuria 尿频，尿急和尿痛 Incontinence of urine 尿失禁 Retention of urine 尿潴留（1）发热的表示方法 Infective (Septic)fever 感染性发热 Non-infective (Aseptic)fever 非感染性发热 Dehydration (Inanition)fever 脱水热 Drug fever 药物热 Functional hypothermia 功能性低热 Absorption fever 吸收热 Central fever 中枢性发热 Fever type 热型 Continuous fever 稽留热 Remittent fever 驰张热 Intermittent fever 间歇热 Undulant fever 波状热 Recurrent fever 回归热 Periodic fever 周期热 Irregular fever 不规则热 Ephemeral fever 短暂热 Double peaked fever 双峰热 Fever of undetermined(unknown) origin, FUO 不明原因发热 Rigor (shivering;chill;shaking chill;ague) 寒战 Chilly Sensation (Fell chilly;cold fits;coldness) 畏寒 Ultra-hyperpyrexia 超高热 Hyperthermia (A high fever;hyperpyrexia;ardent fever) 高热 Moderate fever 中度发热 Hypothermia (Low-grade fever;slight fever;subfebrile temperature) 低热 Become feverish (Have a temperature) 发热 Crisis 骤降 Lysis 渐降 Typhoid fever 伤寒热 Rheumatic fever 风湿热 Cancerous fever 癌性发热 Fervescence period 升热期 Defervescence period 退热期 Persistent febrile period 持续发热期（2）疼痛的表示方法 Backache (Back pain) 背痛 Lumbago 腰痛 Headache 头痛 Vasomotor headache 血管舒缩性头痛Post-traumatic headache 创伤后头痛Migraine headache 偏头痛 Cluster headache 丛集性头痛 Chest pain 胸痛 Precardial pain 心前区痛 Retrosternal pain 胸骨后痛 Abdominal pain (Stomachache) 腹痛 Acrodynia (pain in limbs) 肢体痛 Arthrodynia (Arthralgia) 关节痛 Dull pain 钝痛 Sharp pain 锐痛 Twinge pain 刺痛 Knife-like pain (Piercing pain) 刀割（刺）样痛 Aching pain 酸痛 Burning pain 烧灼痛 Colicky (Griping;cramp) pain 绞痛 Colic 绞痛 Bursting pain 胀痛（撕裂痛） Hunger pain 饥饿痛 Tic pain 抽搐痛 Bearing-down pain 坠痛 Shock-like pain 电击样痛 Jumping pain 反跳痛 Tenderness pain 触痛（压痛） Girdle-like pain 束带样痛 Wandering pain 游走性痛 Throbbing pain 搏动性痛 Radiating pain 放射性痛 Cramping pain 痉挛性痛 Boring pain 钻痛 Intense pain 剧痛 Writhing pain 痛得打滚 Dragging pain 牵引痛 Labor pain 阵痛 Cancerous pain 癌性疼痛 Referred pain 牵涉痛 Persistent pain (Unremitting pain) 持续性痛 Constant pain 经常性痛 Intermittent pain 间歇性痛（3）水肿的表示方法 Mucous edema (Myxedema) 粘液性水肿 Cardiac (Cardiogenic) edema 心源性水肿 Nephrotic (renal) edema 肾源性水肿 Hepatic edema 肝源性水肿 Alimentary (Nutritional) edema 营养不良性水肿 Angioneurotic edema 血管神经性水肿 Pitting 凹陷性 Nonpitting 非凹陷性 Localized (Local) edema 局限性水肿 Generalized edema (Anasarca) 全身性水肿 Hydrops 积水 Elephantiasic crus 橡皮肿 Cerebral(Brain) edema 脑水肿 Pulmonary edema (Hydropneumonia0 肺水肿 Hydrocephalus 脑积水 Edema of endoscrinopathy 内分泌病性水肿 Invisible (Recessive) edema 隐性水肿 Frank edema 显性水肿 Inflammatory edema 炎性水肿 Idiopathic edema 特发性水肿 Cyclical edema 周期性水肿 Ascites (Abdominal effusion;hydroperiotoneum) 腹水 Pleural effusion (Hydrothorax) 胸水 Pericardial effusion (Hydropericardium) 心包积液 Bronchoedema 支气管水肿 Slight (Mild) 轻度 Moderate 中度 Serious 重度 Transudate 漏出液 Exudate 渗出液（4）呼吸困难的表示方法 Cardiac dyspnea 心原性呼吸困难 Inspiratory 吸气性 Expiratory 呼气性 Mixed 混合性 Obstructive 梗阻性 Dyspnea at rest 静息时呼吸困难 Dyspnea on exertion 活动时呼吸困难 Dyspnea on lying down 躺下时呼吸困难 Paroxysmal nocturnal dyspnea,PND 夜间阵发性呼吸困难 Orthopnea 端坐呼吸 Asthma 哮喘 Cardiac asthma 心源性哮喘 Bronchial asthma 支气管性哮喘 Hyperpnea 呼吸深快 Periodic breathing 周期性呼吸 Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)气促 Bradypnea (Slow breathing) 呼吸缓慢 Irregular breathing 不规则呼吸（5）皮肤粘膜出血的表示方法 Bleeding spots in the skin 皮肤出血点 Petechia 瘀点 Eccymosis 瘀斑 Purpura 紫癜 Splinter hemorrhage 片状出血 Oozing of the blood (Errhysis) 渗血 Blood blister (Hemophysallis) 血疱 Hemorrhinia (Nasal bleeding) 鼻衄 Ecchymoma 皮下血肿（6）咳嗽与咯痰的表示方法 Dry cough (Nonproductive cough;hacking cough) 干咳 Sharp cough 剧咳 Wet cough (Moist cough) 湿咳 Productive cough (Loose cough) 排痰性咳 Chronic cough 慢性咳嗽 Irritable cough 刺激性咳嗽 Paroxysmal cough 发作性（阵发性）咳嗽 Cough continually 持续性咳嗽 Spasmodic cough 痉挛性咳嗽 Whooping cough 百日咳 Winter cough 冬季咳 Wheezing cough 喘咳 Short cough 短咳 Distressed cough 难咳 Shallow cough 浅咳 Droplet 飞沫 Frothy sputum 泡沫样痰 Bloody sputum 血痰 Mucous (Mucoid) sputum 粘液样痰 Purulent sputum 脓痰 Mucopurulent sputum 粘液脓性痰 White (Yellow,green) sputum 白（黄,绿）痰 Fetid (Foul) sputum 恶臭痰 Iron-rust (Rusty) sputum 铁锈色痰 Chocolate coloured sputum 巧克力色痰 Thick sputum 浓痰 Thin sputum 淡痰 Viscous sputum 粘痰 Transparent sputum 透明痰 Much (Large amounts of) sputum 大量痰 Moderate amounts of sputum 中等量痰 Not much (Small amounts of ) sputum 少量痰（7）内脏出血的表示方法 Goldsteins hemoptysis戈耳斯坦氏咯血 Massive hematemesis大量呕血 Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)鼻衄 Hematuria 血尿 Initial hematuria 初血尿 Idiopathic hematuria 特发性血尿 Painless hematuria 无痛性血尿 Terminal hematuria 终末性血尿 Gross (Macroscopic) hematuria 肉眼血尿 Microscopic hematuria 镜下血尿 Hematuria in the whole process of urination 全程血尿 Gingival bleeding (Ulaemorrhagia;gum bleeding) 牙龈出血 Hematochezia 便血 Bloody stool 血便 Black stool (Melena) 黑便 Tarry stool 柏油样便 Bleeding following trauma 外伤后出血 Spontaneous bleeding 自发性出血 Bleeding Continuously 持续出血 Occult blood,OB 隐血 Hematobilia 胆道出血 Hemathorax 血胸 Hemarthrosis 关节积血 Hematocoelia 腹腔积血 Hematoma 血肿 Hemopericardium 心包积血 Cerebral hemorrhage 脑出血 Subarachnoid hemorrhage(SAH) 蛛网膜下腔出血 Excessive (Heavy) menstrual flow with passage of clots 月经量多伴血块 Mild (Moderate) menses 月经量少（中等） Painless Vaginal bleeding 无痛性阴道出血 Postcoital bleeding 性交后出血 Pulsating bleeding 搏动性出血 Post-operation wound hemorrhage 术后伤口出血 Excessive bleeding after denal extraction 拔牙后出血过多（8）紫绀的表示方法 Congenital cyanosis 先天性紫绀 Enterogenous 肠源性 Central 中枢性 Peripheral 周围性 Mixed 混合性 Acrocyanosis 指端紫绀（9）恶心与呕吐的表示方法 Vomiturition (Retching) 干呕 Feel nauseated 恶心感 Postprandial nausea 饭后恶心 Hiccup 呃逆 Sour regurgitation 返酸 Fecal (Stercoraceous) vomiting 吐粪 undigested food Vomiting 吐不消化食物 Bilious Vomiting 吐胆汁（10）腹泻与便秘的表示方法 Moning diarrhea 晨泻 Watery (Liquid)diarrhea 水泻 Mucous diarrhea 粘液泻 Fatty diarrhea 脂肪泻 Chronic (Acute) 慢性（急性） Mild diarrhea 轻度腹泻 Intractable (Uncontrolled)diarrhea 难治性腹泻 Protracted diarrhea 迁延性腹泻 Bloody stool 血梗 Frothy stool 泡沫样便 Formless (Formed)stool 不成形（成形）便 Loose (Hard) stool 稀（硬）便 Rice-water stool 米泔样便 Undigested stool 不消化便 Dysenteric diarrhea 痢疾样腹泻 Inflammatory diarrhea 炎症性腹泻 Osmotic 渗透性 Secretory 分泌性 Malabsorption 吸收不良性 Lienteric 消化不良性 Pancreatic diarrhea 胰性腹泻 Tenesmus 里急后重 Pass a stool (Have a passage; open or relax the bowel) 解大便 Have a call of nature 便意 Fecal incontinence (Copracrasia) 大便失禁 Functional constipation 功能性便秘 Organic constipation 器质性便秘 Habitual constipation 习惯性便秘 Have a tendency to be constipated 便秘倾向（11）黄疸的表示方法 Latent (occult) jaundice 隐性黄疸 Clinical jaundice 显性黄疸 Nuclear icterus 核黄疸 Physiologic icterus 生理性黄疸 Icterus simplex 传染性黄疸 Toxemic icterus 中毒性黄疸 Hemolytic 溶血性 Hepatocellular 肝细胞性 Obstructive 阻塞性 Congenital 先天性 Familial 家族性 Cholestatic 胆汁淤积性 Hematogenous 血源性 Malignant 恶性 Painless 无痛性（12）意识障碍的表示方法 Somnolence 嗜睡 Confusion 意识模糊 Stupor 昏睡 Coma 昏迷 Delirium 谵妄 Syncope (swoon; faint) 晕厥 Drowsiness 倦睡（13）排尿的表示方法 Enuresis (Bed-wetting) 遗尿 Anuria 无尿 Emiction interruption 排尿中断 Interruption of urinary stream 尿线中断 Nocturia 夜尿 Oliguria 少尿 Polyuria 多尿 Pass water (Make water; urinate; micturition) 排尿 Frequent micturition (Frequency of micturition; fruquent urination; Pollakiuria) 尿频 Urgent micturition (Urgency of urination or micturition) 尿急 Urodynia (Pain on micturition; painful micturition; alginuresis; micturition pain) 尿痛 Dysuria (Difficulty in micturition; disturbance of micturition) 排尿困难 Small urinary stream 尿线细小 Void with a good stream 排尿通畅 Guttate emiction (Dribbling following urination;terminal dribbling) 滴尿 Bifurcation of urination 尿流分叉 Residual urine 残余尿 Extravasation of urine 尿外渗 Stress incontinence 压力性尿失禁 Overflow incontinence 溢出性尿失禁 Paradoxical in continence 反常性尿失禁3少见症状 Weekness( Debility; asthenia; debilitating) 虚弱（无力） Fatigue (Tire; lassitude) 疲乏 Discomfort (Indisposition; malaise) 不适 Wasting (thin; underweight; emaciation; lean) 消瘦 Night sweating 盗汗 Sweat (Perspiration) 出汗 Cold sweat 冷汗 Pruritus (Iching) 搔痒 Asthma 气喘 Squeezing (Tightness; choking; pressing) sensation of the chest 胸部紧缩（压榨）感 Intermittent claudication 间歇性跛行 Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis) 吞咽困难 Epigastric (Upper abdominal) discomfort 上腹部不适 Anorexia (Sitophobia) 厌食 Poor appetite (Loss of appetite) 纳差 Heart-burn( Pyrosis) 胃灼热 Stomachache( Pain in stomach) 胃部痛 Periumbilial pain 脐周痛 Belching (Eructation) 嗳气 Sour regurgitation 返酸 Abdominal distention(bloating) 腹胀 Pass gas( Break wink) 肛门排气 Small(Large) stool 大便少（多） Expel(Pass) worms 排虫 Pain over the liver 肝区痛 Lumbago 腰痛 Pica(Parorexia; allotriophagy) 异食癖 Dysmenorrhea 痛经 Menoxenia (Irregular menstruation) 月经不调 Polymenorrhea (Epimenorrhea) 月经过频 Oligomenorrhea 月经过少 Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea) 经量过多 Hypomenorrhea (Scantymenstruation) 经量过少 Menopause (Menostasia; menostasis) 绝经 Amenorrhea (Menoschesis) 闭经 Leukorrhagia 白带过多 Asexuality (lack of libido) 无性欲 Hyposexuality 性欲低下 Hypersexuality 性欲亢进 Prospermia (Ejaculatio praecox) 早泄 Impotency (impotence) 阳萎 Nocturnal emission (Spermatorrhea) 遗精 Lack of potency 无性交能力 Hair loss 脱发 Joint pain