【導(dǎo)讀】隨著我國(guó)加入WTO，醫(yī)療體制發(fā)生了革命性的改變。隨著改革開放的深入，外國(guó)投資。人員逐年增多，這就要求醫(yī)生具有正確書寫英文病歷的能力。目前，國(guó)內(nèi)供臨床醫(yī)生完成英。文病歷的參考書很少。簽于此，編著者根據(jù)美國(guó)羅馬琳達(dá)大學(xué)的病歷書寫要求，結(jié)合十余年。合性醫(yī)院，有十余年的英文病歷書寫實(shí)踐），并參閱一些國(guó)內(nèi)外的相關(guān)文獻(xiàn)，編寫了本手冊(cè)。新穎，適用于臨床醫(yī)生、出國(guó)人員、實(shí)習(xí)生和醫(yī)學(xué)院校的學(xué)生。逸夫醫(yī)院領(lǐng)導(dǎo)的關(guān)心和支持。謹(jǐn)以此書獻(xiàn)給我的老師、同事、朋友和家人。·[,QingChunRoadEast,Hangzhou,Zhejiang]浙江省杭州市慶春東路3號(hào)

　　

【正文】 ▲ 5年前 [5 years ago] ▲ 直到一個(gè)月前 [Up to one month ago] ▲ 大前天 [Three days ago] Prior to[在??之 前 ] ▲ 入（出）院前 [Prior to admission (discharge)] ▲ 前天之前 [Prior to the day before yesterday] Up to[直到 ] ▲ 直到 3周前 [Up to 3 weeks ago] ▲ 直到現(xiàn)在（出院） [Up to now (discharge)] Until or till[直到 ] ▲ 直到 80歲 [Until 80 years old] ▲ 直到今晨 8點(diǎn) [Until 8 o`clock this moning] ▲ 直到醫(yī)生查完房 [Until the doctor have finished the ward round] ▲ 直到 3年以前 [Until 3 years ago] ▲ 直到出院前一天 [Until 1 day prior to discharge] By[在??之前 ] ▲ 下午點(diǎn)鐘前 [By 5 PM] ▲ 下個(gè)月之前 [By next month] Since[從??開始 ] ▲ 自從去年術(shù)后 [Since operation was performed last year] ▲ 前天起 [Since the day before yesterday] ▲ 從 2020年 6月起 [Since June 2020] 超時(shí) (加班 )[Overtime] 上午 8點(diǎn) [8： 00AM] 下午 2點(diǎn) 30分 [2： 30PM] 7點(diǎn) 50分 [Seven fifty (Ten to eight)] 9點(diǎn) 20分 [Nine twenty(Twenty past or after nine)] 術(shù)前 [Preoperation] 術(shù)后 [Postoperation] 第三章 現(xiàn)病史 [History of present illness (HPI/PI)] 現(xiàn)病史書寫的重點(diǎn)包括： 一、主訴中癥狀的詳細(xì) 描述； 二、疾病的發(fā)展過程； 三、診療經(jīng)過； 四、目前的一般情況。 誘因 無(wú)誘因下 [With no inducing factors] 無(wú)明顯誘因下 [Under no obvious predisposing causes] 感冒一周后 [After getting (catching) mon cold for 1 week] 癥狀出現(xiàn)的敘述 有??癥狀 ▲ suffer from ▲ have an attack of ▲ have(fell) ▲ begin to fell ▲ a feeling (sensation) of?? ▲ plain (of) ▲ ?? sensation (feeling) in (of) ?? ▲ [發(fā)熱 ]have a temperature (bee feverish) 在??情況下發(fā)生 ▲ 活動(dòng)時(shí)呼吸困難 [dyspnea on exertion] ▲ 躺下后即出現(xiàn)咳嗽 [Cough occurs soon after lying] 與??有（無(wú)）關(guān) ▲ 與??有關(guān) [be associated with] ▲ 與??有關(guān) [have (make) relation to] ▲ 與??無(wú)關(guān) [have (make)no relation to] 在??情況下加重（減輕） ▲ 餐后加重 [bee worse after taking meals] ▲ 站立后緩解 [be relieved by standing up] ▲ 隨呼吸和咳嗽而加重 [bee more severe with breathing and cough] 伴有?? ▲ be acpanied by 起病方式 急性腹痛 [acute abdominal pain] 慢性低熱 [chronic lower fever] 暴發(fā)性發(fā)病 [the onset was fulminating] 驟起胸痛 [an explosive onset of chest pain] 突然起病伴高熱 [the onset was sudden with high fever] 突發(fā)突止 [attacks began and ended abruptly] 因??而突然起病 [the attack is precipitated by?? ] 很快發(fā)生暈厥 [syncope occured rapidly] 逐漸出現(xiàn)咳嗽咳痰 [gradual onset of cough and sputum] 偶而 [occasionally (sporadically, accidentally)] 反復(fù)胸悶心悸 [recurrent (bouts of) chest disfort and palpitation] 一過性發(fā)作 [transitory attack] 連續(xù)胸痛 [chest pain continually] 時(shí)重時(shí)輕 [waned and waxed] 時(shí)好時(shí)壞 [hang in the balance] 不停地咳嗽 [have a fit of cough] 發(fā)作性呼吸困難 [paroxysmal short of breath] 頻繁咳嗽 [cough frequently (very often)] 持續(xù)性（間歇性） [persistent (intermittent)] 頻發(fā)胸痛 [frequent episodes of chest pain] 持續(xù)不變 [be steady] 病情變化描述 [癥狀好轉(zhuǎn) ] ▲ fell better than before ▲ take a favorable turn ▲ take a turn for the better ▲ improve ▲ make favorable progress ▲ turn for the better ▲ change for the better ▲ be better [癥狀減輕 ] ▲ alleviate ▲ reduce ▲ palliate ▲ diminish ▲ ease(lighten) ▲ mitigate [癥狀消失 ] ▲ disappear ▲ subside ▲ regress ▲ clear up ▲ vanish ▲ dissolve ▲ die (fade) away ▲ relieve [癥狀加重 ] ▲ be (make,bee,get) worse ▲ worsen ▲ bee more severe ▲ take a turn for the worse ▲ be aggravated ▲ increase in severity ▲ take a bad turn ▲ make (bee) more serious ▲ make (bee) heavier [無(wú)變化 ] ▲ remain the same as?? ▲ continue without change ▲ be identical ▲ be alike ▲ be similar ▲ resemble [時(shí)好時(shí)壞 ]▲ wane and wax ▲ hang in the balance [體 溫 /血壓升降 ] ▲ 升至 [rise (go up) to ] ▲ 已升至 [have risen (gone up) to ] ▲ 從??升至?? [go up from ?? to?? ] ▲ 升至 [be elevated to] ▲ 迅速下降 [fall (decline, abate) abruptly] ▲ 驟降（升） [sudden drop (elevation)] ▲ 漸降（升） [fall (elevate) gradually] ▲ 緩慢下降 [slow crisis (lysis) of ] ▲ 一天天下降 [be (bee) lower day by day] ▲ 開始降低 [begin to remit] ▲ 降至正常 [drop (was reduced) to normal] ▲ 已降至 [have gone down (dropped) to] ▲ 回復(fù)到正常 [return (revert) to normal] ▲ 由??降（升）至?? [fall (elevate) from?? to?? ] ▲ 維持在??水平 [maintain at a level of?? ] ▲ 穩(wěn)定在?? [stabilize at?? ] ▲ 熱退了 [fever disappeared] ▲ 不 超過 [do not go up over (exceed)?? ] ▲ 在??和??之間波動(dòng) [fluctuate (vary) between?? and?? ] ▲ 在??至??范圍內(nèi) [range from?? to?? ] ▲ 平均 ℃ [an average temperature of ℃ ] ▲ 有 ℃ 的體溫 [have fever (a temperature) of ℃ ] 癥狀的時(shí)間表示 持續(xù) ▲ lasted for 2 days ▲ have gone on for 1 month ▲ have continued for 10 hours ▲ lasted on the average 35 hours ▲ lasted a variable time from 5 minutes to several hours ▲ lasted about half an hour 超過（不到） [move than (less than)] ??以前 [two years ago] 多在??時(shí)發(fā)生 [usually between 3 and 5 PM] 未發(fā)作過 [be free of onsets (attacks) for 2 weeks] 癥狀的嚴(yán)重程度 輕度 [mild (slight)] 中度 [moderate] 重度 [severe (serious)] 癥狀的其他描述方法 [部位 ] ▲ be located (situated) in (over)[位于 ] ▲ There is localized pain in?? [疼痛位于 ] ▲ near?? [在??附近 ] ▲ be localized to (in, over)[局限于 ] ▲ be limited (confined) to[局限于 ] [表示部位的介詞 ] ▲ 心尖部，表示小的部位或點(diǎn) [at the apex] ▲ 上腹部，表示大的部位 [in the upper abdomen] ▲ 在左下肢，表示皮膚表面上（下）的病變 [on (beneath) the left lower limb] ▲ 在右肺，表示正上方的相應(yīng)體表部位 [over the right lung] ▲ 嘴上（下）方，表示高低或上下的位置關(guān)系 [above (below) the mouth] ▲ 左乳皮下 [under the skin of the left breast] [轉(zhuǎn)移 /放射 ] ▲ 轉(zhuǎn)移到?? [shift (migrate) to?? ] ▲ 放射到?? [radiate (travel,go,refer)to?? ] ▲ 從??放射到?? [radiate from?? to?? ] [耳鼻咽喉及口腔癥狀 ] ▲ 耳痛 [otalgia (pain of ears)] ▲ 耳鳴 [tinnitus (ears ring)] ▲ 耳鳴 [a buzzing (ringing,singing) in the ears] ▲ 左耳有耳鳴感 [a buzzing sensation in the left ear] ▲ 耳聾 [deafness (loss in hearing)] ▲ 左耳聾 [be deaf of the left ear] ▲ 耳流膿 [otorrhea (otopyorrhea)] ▲ 耳出血 [otorrhagia] ▲ 耳垢 [cerumen (earwax)] ▲ 耳血腫 [othematoma] ▲ 鼻塞 [nasal obstruction] ▲ 不能用鼻呼吸 [be unable to breathe through (by) the nose (nasal dyspnea)]