1、整理有关英文病例的写作，提供大家查考：一、主要调查项目：1.主诉 chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.2.现症历 present illn
2、ess：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite an
3、d strength, sleep, bowel movement, frequency of urination, menstruation, etc.3.既往历 past history：1)former places of residence, previous stage of health( 健壮的 robust，纤弱的delicate), experience with similar disease, immunity to infectious disease2)previous illness：麻疹 measles, 腮腺炎 mumps, 水痘 chicken-pox, 百日
4、咳pertussis, 流行性感冒 influenza, 猩红热 scarlet fever, 白喉 diphtheria，伤寒typhoid fever, 支气管炎 bronchitis, 肺炎 pneumonia，脑炎 encephalitis,脑膜炎meningitis，破伤风 tetanus,小儿麻痹 poliomyelitis,赤痢 dysentery，霍乱 cholera, 胸膜炎 pleurisy,天花 small-pox，疟疾 malaria,结核病 tuberculosis，黄疸病jaundice，过敏性反应 allergy,etc3)venereal disease：spe
5、cific symptoms, signs, and the disease by name, treatment.4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)4.家族历 family history：family tendency, presence of hereditary disorders, cancer, tube
6、rculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patients childhood and adult life, age, health condition, and cause of death of parents
7、, grandparents, self , spouse, siblings , or relatives.5.个人历 personal history：1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home2)Marital history：duration of marriage, 1st or 2nd marriage, age and death
8、 of spouse and children , cause and age at time of death, number of children , pregnancies, 流产次数 miscarriages, 死产数 stillbirths3)occupational history：duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.4)Habits：alcohol, tobacc
9、o, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.6.系统检查 system review：1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.2)Skin：荨麻疹 hives, rash, eczema 3)Head：trauma, head
10、ache, loss of hair4)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, dysphagia9)Neck：adenitis, goiter , rigidity1
11、0)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, frequen
12、cy of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous
13、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 headache13)Neuromuscular：神经过敏 nervousness, emotional stress, weakness, muscle o
14、r 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：H
15、e 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
16、 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。例 1：Whenever he has a cold, he can neither taste nor smell.-知识(knowledge)：believe, (dis)agree, doubt, find, forget, know, mind,
17、remember, think, understand等。例 1：She does not remember specific scratches which might have preceded the present lesions.-感情( emotion)：desire, despise, disgust, fear, hate, hope, (dis)like, love, prefer, want等。例 1：He likes lobster, but it disagrees with him.b)表示继续状态的动词( Verbs of continuous state)：表示存
18、在、所有等动词：appear, be, belong, consist, flow, have, hold, live, look, possess, resemble, seem等。例 1：Her fingers and hands are stiff and cyanotic.例 2：He has no discomfort and eats well.2)A.现在完成式( Have+ p.p)a)表示动作的完了(completion of an action)或其结果的现在状态(present state of things)：例 1：The patient has passed the
19、 crisis. = The patient is out of danger now.例 2：He has caught cold. = He has a cold now.注：常用的连用副词为：all this while, (not) yet, already , just, now, by this time, today, this week( or month, year, etc.), hitherto, till now, up to( till) now, recently, lately, of late等。比较：过去式仅表示过去的动作状态；现在完成式则以表示现在为主。例
20、1：He had no appetite for food. (过去式)表示过去某时有过食欲不振例 2：Lately he had had no appetite for food. (现在完成式)表示现在仍然胃口不佳。b)表示截至现在为止的经验( experience)：例 1：He has seldom consulted a doctor in his life.例 2：He has never been treated by a doctor since he was born.注：表示经验时，常用的副词为：ever, before, once, many times, (very)
21、often, seldom, sometimes, in ones time等副词。比较：同一动词有时表示完了，有时表示经验，视其所连用的副词而决定。例 1：He has just undergone a nephrectomy.表示动作完了。例 2：He has undergone a nephrectomy once.表示经验。c)表示截至现在为止的动作或状态的继续（continuance）例 1：He has been deaf in the left ear since the age of 18 and has experienced slight dizziness on stoo
22、ping.例 2：Except fro a slight loss of energy, he has always felt well.例 3：For the past 10 years he has had persistent and high-pitched tinnitus in his left ear, consisting a buzzing sensation and, occasionally, the sounds of bells.注：常用的连用副词为：since, always, from, for, these, how long？B.现在完成进行式( Have b
23、een +ing)a)表示以前开始的动作继续到现在的状态：例 1：He came here 2 weeks ago, and has been lying sick with a cold since then.例 2：The patient has recently had experience of memory loss and of spells of dizziness. For the preceding 5 years she has been receiving treatment for hypertension.b)表示习惯：例 1：The patient has been
24、 smoking excessively.例 2：She has been chewing a wad of bubble gum all day.注：常用的连用副词为：since, for, how long？,these, form, always等。 比较：例 1：He has been learning medicine for 5 years. (继续)例 2：He has learned medicine for 5 years. (经验)2既往历(past history)：大半用过去式，但发生过去某一定时间以前者，宜用过去完成式；如果疾病发生的前后关系甚明显，或以年代顺序记载时
25、，仍可用过去式。1)A.过去式：用以表示过去的动作、状态、习惯等且与现在的情形毫无关联。a)发生于过去某时者：例 1：An unknown number of years ago he was said to have pneumonia.例 2：In addition to the above symptoms, he noted some vague abdominal pain for a couple of months in the past.例 3：At that time she had a slight nonproductive cough and mild exertion
26、al dyspnea.例 4：Before therapy, she was unable to swallow anything but small sips of water.b)过去某时以后的状态：例 1：In the previous month she noticed that the stools were greatly flattened. Subsequently she became aware of a bearing-down pain the rectum.例 2：Menarche occurred at age 13, thereafter menses were
27、regular, every 28 days, lasting 3 to 4 days each time.例 3：The patient had tinnitus in his left ear 10 years before being discharged for the military service. Several year later, he noted loss of hearing on the left.例 4：In June 1956, a sterilizing operation was performed at a hospital. For the ensuin
28、g 5 months the patient was troubled with intermittent attacks of vague abdominal pain.例 5：Two years after this episode she had one short attack of vertigo but has been attack-free for 2 years.注 1：过去式常用的连用副词：ago, last night, yesterday, the day before yesterday, the other day, this morning , just now等
29、。注 2：现在完成和过去两者都可用的连用副词：just, ever, lately, recently, once, always, already, this morning, today, every night, this week, these few days, for the last few days, since last week, before, yet等。B.表示过去的习惯时，须用 used to , was (were) accustomed to 或 had the habit to 等。用 would来表示过去的习惯时，大抵与 often, sometimes等副词
30、连用。例 1：He used to work far into the night.例 2：He would sometimes come home drunk, and beat his wife.C.过去进行式( Be 动词的过去式+ pres. p.)：表示在过去某一时间正在进行 的动作：例 1：One sister was suffering from active tuberculosis.例 2：He was having mild symptoms of fever and nausea at the time he was seen.例 3：He was raising lar
31、ge amounts of purulent sputum at that time.D.过去完成式( Had + p.p.)：表示截至过去某一时间为止的动作的完了、经验、继续等。a)完了( completion)：例 1：The patient had already expired when he came.例 2：By that time he had immunized against smallpox.连用副词：already, by that time, (not) yet, only just 等。b)经验(experience)：例 1：Till then he had nev
32、er seen so-called bone-setter.例 2：He could not repeat what he had said before.c)继续(continuance)：例 1：He had long been ill in bed.例 2：He had been ill in bed for a long time.E.过去完成进行式(Had been + pres. p.)：表示继续过去某一时间的动作。例 1：Up to that time, he had been drinking mush wine.例 2：Due to her increasing consti
33、pation, she had been taking laxatives daily for one year before admission.比较：例 1：I was sleeping when he came. (过去进行式)例 2：I had been sleeping for an hour before he came.(过去完成进行式)三、家族历1.家族无病：例 1：There is no family history of anemia or other relevant disorders.例 2：The family history did not reveal the
34、occurrence of any congenital anormaly.2.家族历无异状：例 1：Family history was allegedly not remarkable.例 2：His family history was irrelevant to the present illness.例 3：Her family history , besides the fact that her brother died form Dariers disease, was no contributory.例 4：There is nothing important in his
35、direct or collateral hereditary antecedents.3.健康：be in good health；be healthy不健康：have a bad health；be unhealthy例 1：His farther is well with no evidence of illness.例 2：His grandfather 87, is still hale and healthy.4.家族有病：例 1：He is the only member of a family of 5 have Hodgkins disease.例 2：Family hist
36、ory showed chronic gastrointestinal symptoms in a maternal cousin.5.家族有倾向：例 1：There was a strong family history of hemophilia；6 members of the present generation were affected.例 2：There was a high incidence of gallbladder disease in the family.6.过敏：例 1：He had no history of penicillin sensibility, ho
37、wever, he once noted petechiae after taking aspirin.例 2：No asthma, hives or any idiosyncrasy to foods.7.因而死：例 1：His fathers death was coincidental with the patients illness.例 2：His eldest brother died of pneumonia at the age of 28 in the preantiboitic era.四、个人历1.吸烟：例 1：History revealed that he start
38、ed smoking 10 years before, at the age of 23, and has smoked ever since. At first he smoked only a few cigarettes a day butgradually increased this to three-fourths of a package per day, his present rate.例 2：He now smokes an average of 2 packages of cigarettes daily and has averaged this amount for
39、the past 7 years.2.饮酒：例 1：The patient admitted to excessive use of alcohol for years with a grossly inadequate dies.例 2：He customarily consumed up to 2 bottles of beer a day on weekends but denied long period of alcoholic excess or the daily use of alcohol.3.饮食：例 1：The boy never ate any fresh fruits
40、 or vegetables and did not like milk.例 2：She took supplemental multivitamins daily and used a variety of mouthwashes.4.工作：例 1：The patients occupation ( for more than five years) necessitated his breathing acid fumes.例 2：His complaints persisted, and he was unable to resume his regular work.5.分娩：例 1：
41、The history relative to her pregnancy suggested that she was in her 5th month of gestation ( pregnancy).例 2：She is a 30-year-old primigravida with long-standing sterility (infertility).6.其它(卫生、习惯等)：例 1：He spent 3 months visiting Taipei in early 1960 and denied travel outside of Taiwan after that tim
42、e.例 2：The pt. related that she has always lived in Peitou expect for 8 months during 19581959 when she temporarily moved to Tienmoo.例 3：The house was located in a river valley and , therefore, was in a damp, foggy area.例 4：The families of both parents were long residents in the same rural area in Ta
43、itung prefecture.例 5：He was born in a small village of illiterate and primitive parents.例 6：The family had a sick kitten and also kept dogs at the time of the present illness.例 7：He preferred the supine position partially rotated to the right side.例 8：The patient stated that he was in the habit of s
44、pending a great deal of time at the beach during the summer.例 9：She lacked outside interests and was apathetic.例 10：His interests and activities centered mainly on his job.例 11：The patient is not in a good term with his boss.例 12：His income was somewhat above the average for the area in which he liv
45、ed, and he was well satisfied with his present occupation.五、既往历 Past History(1)他一直很健康，到 1960年 10月，才慢慢地开始有咳嗽和脓痰。He had enjoyed good health until Oct. 1960, when he gradually developed coughand purulent sputum.到某时一直健康-几乎未生病 be barely ever sickex1：He had been well until Nov. 1960, at which time he was
46、found to have diabetes mellitus.ex2：He was apparently healthy most of his life, and did not consult a physicianuntil his present illness.(2)以前他没有患过任何病，在幼小时所做的一般免疫，并无不良反应。He had no illnessnes of any kind before and received routine immunizations at an early age without ill effects.未曾患过病ex1：He denied
47、experiencing episode of coughing at any time in his life.ex2：He denied any history of prior cardiovascular symptoms before onset of thepresent illness.(3)他曾患过通常的小儿期疾病和肺炎一次，这些病都顺利痊愈。He had the usual childhood diseases plus one bout of pneumonia from which he made uneventful recoveries.生过病-患病 suffer f
48、rom；have an attack of ；be attacked by-在童年时代患过麻疹，但无合并症发生 have measles during childhoodwithout complications-一起身就会头晕 experience light-headed on sitting up -患严重的喘息性支气管炎 contract severe asthmatic bronchitisex1：He had a lunatic tendency 4 years ago.ex2：He has been a known diabetic since 24 years of age.除
49、病外未患过病ex1：His early development was normal and he suffered no significant illness apart from measles at the age of 5.ex2：Except for childhood disease he has had no more serious diseases untilnow.免疫ex1：He was vaccinated in childhood, and reacted in a routine manner.ex2：The first D.P.T. immunization was given at 3 months, and was followed byhigh fever, lethargy.易患-常常感冒 be subject to frequent colds-容易感冒 be apt to catch cold-多病 prone to illnessex1：Although he was subject to joint pains in his childhood, he gave no definite history of rheumatic fever.ex2：She was su
