英文病例书写(2)

英文病例书写

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。