【正文】 omplainer。offerer。provider) of history] 病史陳術(shù)者? [Reliability of history] 病史可靠程試? [Medical security (Type of payment)] 醫(yī)療費(fèi)用? [Type of admission (Patient condition)] 住院類別（入院時(shí)病情）? [Medical record No.] 病歷號(hào)? [Clinic diagnosis] 門診診斷? [Date of admission (admission date)] 入院日期 [Date of record] 記錄日期年齡的表示方法（以36歲為例）?36 years old (y/o)?Age 36?36 yearold?The age of 36?36 years of age性別的表示方法? [Male,♂] 男性? [Female,♀] 女性職業(yè)的表示方法?工人[Worker] ?退休工作[Retired worker]?農(nóng)民[Farmer (peasant)] ?干部[Leader (cadre)]?行政人員[administrative personnel (staff)]?職員[staff member] ?商人[Trader (Businessman)]?教師[Teacher] ?學(xué)生[Student] ?醫(yī)生[Doctor]?藥劑師[Pharmacist]?護(hù)士[Nurse] ?軍人[Soldier] ?警察[Policeman]?工程師[Engineer] ?技術(shù)員[Technician] ?家政人員[Housekeeper]?家庭主婦[Housewife] ?營業(yè)員[Assistant] ?服務(wù)員[Attendant]?售票員[Conductor] 民族的表示方法 ?漢[Han] ?回[Hui] ?蒙[Meng] ?藏[Tibetan]?朝鮮[Korean]?美國人[American] ?日本人[Japanese] ?英國人[Britisher]醫(yī)療費(fèi)用的表示方法? [Self pay (Individual medical care)] 自費(fèi)? [Government insruance (Public medical care)] 公費(fèi)? [Insurance] 保險(xiǎn)? [Local insurance] 本地醫(yī)保? [Nonlocal in surance] 外地醫(yī)保? [Labor protestion care] 勞保婚姻狀況的表示方法? [Married] 已婚 ? [Single (Unmarried)] 未婚 ? [Diverced] 離婚? [Widow] 寡婦 ? [Widower] 鰥夫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] 無法獲得住址的表示方法?[,Qing Chun Road East,Hangzhou, Zhejiang] 浙江省杭州市慶春東路3號(hào)?[XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.] 浙江省諸暨市（縣）城關(guān)鎮(zhèn)新東村病史陳述者的表示方法? [Patient himself (herself)] 患者本人? [Her husband] 患者的丈夫? [His wife] 患者的妻子? [Patient`s colleague] 患者的同事? [Patient`s neighbor] 患者的鄰居? [Patient`s Kin (Mother。 daughter。Sister)] 患者的親屬(父親、母親、兒子、女兒、兄弟、姐妹)? [Taximan] 出租車司機(jī)? [Traffic police] 交通警察日期的表示方法?2002年10月1日[1012002(10/1/2002。 ,2002)](美國)?2002年10月1日[1102002(1/10/2002。 1st of Oct.,2002)] (英國)1住院類別的表示方法? [Emergent (Emergency call)] 急診? [Urgent] 危重? [Elective (General)] 一般（普通）1入院時(shí)病情的表示方法? [Stable] 穩(wěn)定 ? [Unstable] 不穩(wěn)定? [Relative stable] 相對(duì)穩(wěn)定? [Critical (Imminent)] 危重? [Fair (General)] 一般第二章 主訴[Chief Complaint]主訴的表示方法：癥狀+時(shí)間（Symptom+Time）?癥狀+for+時(shí)間如： [Chest pain for 2 hours] 胸痛2小時(shí)?癥狀+of+時(shí)間如： [Nausea and vomiting of three days` duration] 惡心嘔吐3天?癥狀+時(shí)間+in duration如： [Headache 1 month in duration] 頭痛1月?時(shí)間+of+癥狀如： [Twoday history of fever] 發(fā)熱2天常見癥狀? [Fever] 發(fā)熱? [Pain] 疼痛? [Edema] 水腫? [Mucocutaneous hemorrhage (bleeding)] 皮膚粘膜出血? [Dyspnea (Difficuly in breathing。short of breath)] 呼吸困難? [Cough and expectoration (Sputumhlegm)] 咳嗽和咯痰? [Hemoptysis] 咯血? [Cyanosis] 紫紺? [Palpitation] 心悸? [Chest disfort] 胸悶? [Nausea (Retch。 Dizziness)] 眩暈? [Jaundice (Icterus)] 黃疸? [Convulsion] 驚厥? [Disturbance of consciousness] 意識(shí)障礙? [Hematuria] 血尿? [Frequent micturition,urgent micturition and dysuria] 尿頻，尿急和尿痛? [Incontinence of urine] 尿失禁? [Retention of urine] 尿潴留（1）發(fā)熱的表示方法? [Infective (Septic)fever] 感染性發(fā)熱? [Noninfective (Aseptic)fever] 非感染性發(fā)熱? [Dehydration (Inanition)fever] 脫水熱? [Drug fever] 藥物熱? [Functional hypothermia] 功能性低熱? [Absorption fever] 吸收熱? [Central fever] 中樞性發(fā)熱? [Fever type] 熱型▲ [Continuous fever] 稽留熱▲ [Remittent fever] 馳張熱▲ [Intermittent fever] 間歇熱▲ [Undulant fever] 波狀熱▲ [Recurrent fever] 回歸熱▲ [Periodic fever] 周期熱▲ [Irregular fever] 不規(guī)則熱▲ [Ephemeral fever] 短暫熱▲ [Double peaked fever] 雙峰熱? [Fever of undetermined(unknown) origin, FUO] 不明原因發(fā)熱? [Rigor (shivering。shaking chill。cold fits。hyperpyrexia。slight fever。cramp) pain] 絞痛? [Colic] 絞痛? [Bursting pain] 脹痛（撕裂痛）? [Hunger pain] 饑餓痛? [Tic pain] 抽搐痛? [Bearingdown pain] 墜痛? [Shocklike pain] 電擊樣痛? [Jumping pain] 反跳痛? [Tenderness pain] 觸痛（壓痛）? [Girdlelike pain] 束帶樣痛? [Wandering pain] 游走性痛? [Throbbing pain] 搏動(dòng)性痛? [Radiating pain] 放射性痛? [Cramping pain] 痙攣性痛? [Boring pain] 鉆痛? [Intense pain] 劇痛? [Writhing pain] 痛得打滾? [Dragging pain] 牽引痛? [Labor pain] 陣痛? [Cancerous pain] 癌性疼痛? [Referred pain] 牽涉痛? [Persistent pain (Unremitting pain)] 持續(xù)性痛? [Constant pain] 經(jīng)常性痛? [Intermittent pain] 間歇性痛（3）水腫的表示方法? [Mucous edema (Myxedema)] 粘液性水腫? [Cardiac (Cardiogenic) edema] 心源性水腫? [Nephrotic (renal) edema] 腎源性水腫? [Hepatic edema] 肝源性水腫? [Alimentary (Nutritional) edema] 營養(yǎng)不良性水腫? [Angioneurotic edema] 血管神經(jīng)性水腫? [Pitting] 凹陷性? [Nonpitting] 非凹陷性? [Localized (Local) edema] 局限性水腫? [Generalized edema (Anasarca)] 全身性水腫? [Hydrops] 積水? [Elephantiasic crus] 橡皮腫? [Cerebral(Brain) edema] 腦水腫? [Pulmonary edema (Hydropneumonia0] 肺水腫? [Hydrocephalus] 腦積水? [Edema of endoscrinopathy] 內(nèi)分泌病性水腫? [Invisible (Recessive) edema] 隱性水腫? [Frank edema] 顯性水腫? [Inflammatory edema] 炎性水腫? [Idiopathic edema] 特發(fā)性水腫? [Cyclical edema] 周期性水腫? [Ascites (Abdominal effusion。accelerated breathing。hacking cough)] 干咳? [Sharp cough] 劇咳? [Wet cough (Moist cough)] 濕咳? [Productive cough (Loose cough)] 排痰性咳? [Chronic cough] 慢性咳嗽? [Irritable cough] 刺激性咳嗽? [Paroxysmal cough] 發(fā)作性（陣發(fā)性）咳嗽? [Cough continually] 持續(xù)性咳嗽? [Spasmodic cough] 痙攣性咳嗽? [Whooping cough] 百日咳? [Winter cough] 冬季咳? [Wheezing cough] 喘咳? [Short cough] 短咳? [Distressed cough] 難咳? [Shallow cough] 淺咳? [Droplet] 飛沫? [Frothy sputum] 泡沫樣痰? [Bloody sputum] 血痰? [Mucous (Mucoid) sputum] 粘液樣痰? [Purulent sputum] 膿痰? [Mucopurulent sputum] 粘液膿性痰? [White (Yellow,green) sputum] 白（黃,綠）痰? [Fetid (Foul) sputum] 惡臭痰? [Ironrust (Rusty) sputum] 鐵銹色痰? [Chocolate coloured sputum] 巧克力色痰? [Thick sputum] 濃痰? [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）內(nèi)臟出血的表示方法? [Goldstein’s hemoptysis]戈耳斯坦氏咯血? [Massive hematemesis]大量嘔血? [Epistasis (Nosebleed。 Hemorrhinia。gum bleeding)] 牙齦出血? [Hematochezia] 便血? [Bloody stool] 血便? [Black stool (Melena)] 黑便? [Tarry stool] 柏油樣便? [Bleeding following trauma] 外傷后出血? [Spontaneous bleeding] 自發(fā)性出血? [Bleeding Continuously] 持續(xù)出血? [Occult blood,OB] 隱血