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您现在的位置: 医学全在线 > 医学英语 > 英语教学 > 英文病历 > 正文:英文病历全攻略(七)-陈诉
    

如何写英文病历(七)-陈诉

七、陈诉 Complaint
(1)陈诉的写法
ex1:因为以前患过结核病,他有时诉说咳嗽、胸部不舒服和疲劳。
Having suffered from tuberculosis in the past, he complained occasionally
of coughing, chest discomfort, and prostration.
ex2:她在1961年住院,诉说最近发生中胸部痛、呼吸短促和心悸
In 1961 she was admitted to the hospital complaining of (with complaint of ;because of ) mid-chest pain of recent onset, breathlessness and palpitations.

(2)~感
-恐惧(眩晕、恶心、寒颤)感 a sensation of fear (giddiness, nausea, chill)
-异物(压迫、窒息、烧灼、寒颤)感 foreign body (oppressive, strangling,
burning, chilly) sensation (feeling)
-喉头的痒感 itching sensation in one's larynx
-模糊不舒服的感觉 vague ill feeling
-咽喉上的束紧感 a feeling of constriction in one's throat
-在咽喉右边的微痒感 a tickling feeling in the right side of the throat
-在~后头部的特殊、难堪的感觉 a peculiar, weighty feeling in the back of one's head
-在右上腹部深处的模糊不舒适感 a vague sense of unease deep in the right upper abdominal quadrant
ex1:她近来感觉,似有东西压在膀胱上。
She has recently had (experienced) a sensation of something pressing on the bladder.
ex2:他面部有麻木感。
He has a feeling of numbness of his face.

(3)主诉:应尽可能引用病人的话,说出现症的主要症状,经过期间和找
医师看病的原因。记述需扼要简明并避免含糊语句,常用可用
简写的方式。
ex1:从昨晚饭后,病人一直感觉寒战。
Patient has had chills after dinner since last evening.

可简写为Chills since last evening.
ex2:主诉:胃肿胀已4个月。
C.C.:“Swelling of the stomach“ for 4 months.
ex3:2,3个月来,一做工就感觉呼吸困难和眩晕。
For 2 or 3 months, dyspnea and dizziness on work.

(4)病历的申述
-不完全可靠 be not entirely reliable
-不甚明晰 be not clearly defined
-有些模糊 be somewhat vague
-无法获得 be unobtainable
-不能申述适当的病历 can give no adequate history
-混乱不很肯定 be uncertain and confused
ex1:关于既往症,他不能提供可靠的报告。
He could not give reliable information concerning former illness.
ex2:因为他有精神激动,无法获得可靠的病历。
Because of his mental agitation, no reliable history could be obtained.

(5)因~病而转入~科治疗医学.全在线www.med126.com
ex1:她因为在皮肤科住院治疗未见转好,而被介绍过来。
She was referred because there had been no relief with dermatologic treatment, including hospitalization.
ex2:此病人现年27岁,是刚离婚的经产妇,经一所地方医院诊断 为阴道肿瘤而转入本院。
The patient was a 27-year-old recently divorced multipara referred from a district hospital with a diagnosis of a vaginal tumor.

(6)全身状态
-精力缺失 lack of energy
-只诉说全身无力 complain only a slight generalized weakness
-觉得遍身无力 feel week all over
-不可言状的眩晕 nondescript dizziness
-胸骨下方的不舒服灼感 substernal burning discomfort
-饭后腹上部窘迫感 postprandial epigastric distress
-心脏部疼痛 precordial pain
-胸内苦闷或重压感 precordial oppression;pressure on the chest;tightness in the chest
-全年性的过敏性鼻炎 perennial allergic rhinitis
-季节性的支气管性喘息 seasonal bronchial asthma
-一直不断地说胃痛和头痛 incessant complaints of stomach pains and headaches
-尤其喝一杯牛奶后,有些不舒服的饱胀感 some uncomfortable full feeling especially after drinking one glass of milk
-偶而一时丧失意识 have occasional blackouts
-肩僵硬 stiff shoulder
-觉气闷,觉气息不舒 feel stifling (suffocating)
-感觉疲乏 become tired ( fatigued, weary);have a tired feeling;feel languid
-觉全身寒栗 feel a cold shuddering pass all through~
-觉得浑身发冷 fell a chill creep over~
-头晕目眩 one's eyes swim in one's head
-(~的)脚麻木 have a charlie horse (in one's leg)
ex1:他差不多不断地诉说饭后呕吐
He complained almost ceaselessly of postprandial nausea.
ex2:全身虚弱,而腿痛变得很厉害。
There was general debility, and pain in the legs become excruciating.

 

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