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您現(xiàn)在的位置: 醫(yī)學(xué)全在線 > 醫(yī)學(xué)英語 > 英語教學(xué) > 英文病歷 > 正文:英文病歷全攻略(七)-陳訴
    

如何寫英文病歷(七)-陳訴

七、陳訴 Complaint
(1)陳訴的寫法
ex1:因為以前患過結(jié)核病,他有時訴說咳嗽、胸部不舒服和疲勞。
Having suffered from tuberculosis in the past, he complained occasionally
of coughing, chest discomfort, and prostration.
ex2:她在1961年住院,訴說最近發(fā)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
-恐懼(眩暈、惡心、寒顫)感 a sensation of fear (giddiness, nausea, chill)
-異物(壓迫、窒息、燒灼、寒顫)感 foreign body (oppressive, strangling,
burning, chilly) sensation (feeling)
-喉頭的癢感 itching sensation in one's larynx
-模糊不舒服的感覺 vague ill feeling
-咽喉上的束緊感 a feeling of constriction in one's throat
-在咽喉右邊的微癢感 a tickling feeling in the right side of the throat
-在~后頭部的特殊、難堪的感覺 a peculiar, weighty feeling in the back of one's head
-在右上腹部深處的模糊不舒適感 a vague sense of unease deep in the right upper abdominal quadrant
ex1:她近來感覺,似有東西壓在膀胱上。
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)主訴:應(yīng)盡可能引用病人的話,說出現(xiàn)癥的主要癥狀,經(jīng)過期間和找
醫(yī)師看病的原因。記述需扼要簡明并避免含糊語句,常用可用
簡寫的方式。
ex1:從昨晚飯后,病人一直感覺寒戰(zhàn)。
Patient has had chills after dinner since last evening.

可簡寫為Chills since last evening.
ex2:主訴:胃腫脹已4個月。
C.C.:“Swelling of the stomach“ for 4 months.
ex3:2,3個月來,一做工就感覺呼吸困難和眩暈。
For 2 or 3 months, dyspnea and dizziness on work.

(4)病歷的申述
-不完全可靠 be not entirely reliable
-不甚明晰 be not clearly defined
-有些模糊 be somewhat vague
-無法獲得 be unobtainable
-不能申述適當(dāng)?shù)牟v can give no adequate history
-混亂不很肯定 be uncertain and confused
ex1:關(guān)于既往癥,他不能提供可靠的報告。
He could not give reliable information concerning former illness.
ex2:因為他有精神激動,無法獲得可靠的病歷。
Because of his mental agitation, no reliable history could be obtained.

(5)因~病而轉(zhuǎn)入~科治療醫(yī)學(xué).全在線www.med126.com
ex1:她因為在皮膚科住院治療未見轉(zhuǎn)好,而被介紹過來。
She was referred because there had been no relief with dermatologic treatment, including hospitalization.
ex2:此病人現(xiàn)年27歲,是剛離婚的經(jīng)產(chǎn)婦,經(jīng)一所地方醫(yī)院診斷 為陰道腫瘤而轉(zhuǎn)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)全身狀態(tài)
-精力缺失 lack of energy
-只訴說全身無力 complain only a slight generalized weakness
-覺得遍身無力 feel week all over
-不可言狀的眩暈 nondescript dizziness
-胸骨下方的不舒服灼感 substernal burning discomfort
-飯后腹上部窘迫感 postprandial epigastric distress
-心臟部疼痛 precordial pain
-胸內(nèi)苦悶或重壓感 precordial oppression;pressure on the chest;tightness in the chest
-全年性的過敏性鼻炎 perennial allergic rhinitis
-季節(jié)性的支氣管性喘息 seasonal bronchial asthma
-一直不斷地說胃痛和頭痛 incessant complaints of stomach pains and headaches
-尤其喝一杯牛奶后,有些不舒服的飽脹感 some uncomfortable full feeling especially after drinking one glass of milk
-偶而一時喪失意識 have occasional blackouts
-肩僵硬 stiff shoulder
-覺氣悶,覺氣息不舒 feel stifling (suffocating)
-感覺疲乏 become tired ( fatigued, weary);have a tired feeling;feel languid
-覺全身寒栗 feel a cold shuddering pass all through~
-覺得渾身發(fā)冷 fell a chill creep over~
-頭暈?zāi)垦?one's eyes swim in one's head
-(~的)腳麻木 have a charlie horse (in one's leg)
ex1:他差不多不斷地訴說飯后嘔吐
He complained almost ceaselessly of postprandial nausea.
ex2:全身虛弱,而腿痛變得很厲害。
There was general debility, and pain in the legs become excruciating.

 

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