2、心内科常用英文病历模板

第二节 心内科常用英文病历模板

熟练地阅读和书写英文病历是一名临床医师需要具备的基本外语技能。对英文病历的熟练掌握对于阅读英文文献和撰写英文论文都有很大的帮助。本章主要介绍心内科常见疾病英文病历的格式和基本模板。英文病历的书写格式大致与中文病历相似，主要包括以下部分：

1.General information（一般情况） 2.Chief complaint（主诉） 3.Present illness（现病史） 4.Past history（既往史） 5.Personal history（个人史） 6.Family history（家族史） 7.Physical examination（体格检查） 8.Investigation（辅助检查） 9.History summary（病史特点） 10.Impression（印象、初步诊断） 11.Signature（签名）

鉴于不同疾病的病历之间存在共性，本章按照病历的通用部分和心血管内科部分逐一进行介绍。

第一部分 通用部分

1. General information（一般情况）

这一部分包括name（姓名），age（年龄），sex（性别），race（民族），nationality（国籍），address（地址和电话），occupation（职业），marital status（婚姻状况），date of admission（入院日期），date of record（记录日期），complainer of history（供史者）和reliability（可信度）等12项内容。基本格式如下：

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心内科英文病历模板

Name: Liu Side Age: Eighty Sex: Male Race: Han Nationality: China

Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: Retired Marital status: Married

Date of admission: Aug 6th, 2001

Date of record: 11Am, Aug 6th, 2001 Complainer

of

history:

patient’s son and wife Reliability: Reliable

2. Past history（既往史）

这一部分应首先总结既往一般健康状况、Operative history（手术史）、Infectious history（传染病史）、Allergic history（过敏史）等，然后对各系统健康状况进行回顾，包括Respiratory system（呼吸系统）、Circulatory system（循环系统）、Alimentary system（消化系统）、Genitourinary system（泌尿生殖系统）、Hematopoietic system（血液系统）、Endocrine system（内分泌系统）、Kinetic system（运动系统）和Neural system（神经系统）。基本格式示例如下： Past history

The patient is healthy before.

No history of infective diseases. No allergy history of food and drugs. Past history

Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin or 2

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sulfamide.

Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation.

Genitourinary system: No history of genitourinary disease.

Hematopoietic system: No history of anemia and mucocutaneous bleeding.

Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness.

3. Personal history（个人史）和Family history（家族史）

这一部分包括患者的出生和居住情况、生活环境情况（疫水疫区接触史）、不良嗜好情况以及Obstetrical history（婚育史）、Menstrual history（月经史）、Contraceptive history（避孕史）等。Family history（家族史）应包括直系亲属生存情况及家族性遗传病史。基本格式示例如下： Personal history

He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient. Obstetrical history: No Contraceptive history: Not clear.

Family history: His parents have both deads. 4. Physical examination（体格检查）

体格检查部分内容比较繁多，应根据全身一般情况、

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心内科英文病历模板

头颈部、胸部、腹部、四肢的顺序逐一描述查体所见，其顺序和格式大致同中文病历。

（1）一般情况

这一部分包括基本生命体征（体温、心率、呼吸、血压）、发育、营养、神志、体位、面容和表情、检查能否合作、全身皮肤黏膜、浅表淋巴结等情况。示例： T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.

（2）各系统体格检查

按照从头部到四肢的顺序逐部位进行描述，与中文病历大致相同。示例： Head

Cranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness. Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.

Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. 4

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Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.

Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline. Chest

Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.

Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.

Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.

Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or

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peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. Extremities: No articular swelling. Free movements of all limbs.

Neural system: Physiological reflexes were existent without any pathological ones.

Genitourinary system: Not examed. Rectum: not examed

5. Investigation（辅助检查）

将重要的辅助检查结果一次记录即可。 6. History summary（病史总结）

这一部分应包括一般特点、主诉、既往史、体格检查、辅助检查等五个方面的简要小结，主要列举与疾病相关的情况和相关阳性结果。大致同中文病历首次病程记录中的病史特点。示例：

1. Patient was male, 80 years old

2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. 3. No special past history.

4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was 6

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untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.

5. Investigation information:

Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L.

7. Impression and Signature（初步诊断和签名） 在这一部分记录对患者的初步诊断并签署记录者的签名。注意在书写格式上应居于页面的右侧。示例：

Impression: upper gastrointestine hemorrhage

Exsanguine shock

Signature: He

Lin (95-10033)

第二部分 心血管专业部分 1. Chief complaint（主诉）

（1）Symptom+Time（症状+时间） Chest pain for 2 hours 胸痛2小时

Chest discomfort and palpitation of three day’s duration 胸闷、心悸3天

Short of breath 1 month in duration 气促1月 Tow-day history of adema on the lower limbs 双下肢水肿2天

（2）心内科常见症状 Ⅰ. 胸痛或不适感

胸闷 chest distress；胸痛 chest pain；心前区痛 precardial pain；胸部不适感 chest diasomfort；胸部紧缩（压榨）感 squeezing（tightness，choking，pressing，constricting，crushing，oppressing，compressing，wiselike，

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心内科英文病历模板

heavy pain）sensation of the chest；濒死感 impending doom；放射至颈部（下颌、上腹部、肩、左上肢）radiating to neck（jaw，epigastrium，shoulders，left arm）；胸骨后痛 retrosternal pain；钝痛 dull pain；刺痛 twinge pain/stabbing；刀割（刺）样痛 knife-like pain/piercing pain；烧灼痛 burning pain；绞痛 colicky（griping，cramp）pain；撕裂痛 tearing pain；静息痛 rest pain；持续性痛 persistent pain（unremitting pain）；间歇性痛 intermittent pain Ⅱ. 呼吸困难的表示方法

呼吸困难 dyspnea（difficulty in breathing，respiratory difficulty，short or shortness of breath）；气促 tachypnea（rapid or fast breathing，accelerated breathing，short of breath）；心源性呼吸困难 cardiac dyspnea；端坐呼吸 orthopnea；夜间阵发性呼吸困难 paroxysmal nocturnal dyspnea，PND；静息时呼吸困难 dyspnea at rest；活动时呼吸困难 dyspnea on exertion；卧位时呼吸困难 dyspnea on lying down Ⅲ. 心悸的表示方法

心慌 flustered；心悸 palpitation；心动过速 tachycardia；心动过缓 bradycardia；心律不齐 arhycardia Ⅳ. 发绀的表示方法

发绀cyanosis；先天性发绀 congenital cyanosis；中枢性 central；周围性 peripheral；混合性 mixed；指端发绀 acrocyanosis

Ⅴ. 意识障碍和睡眠的表示方法

意识障碍 disturbance of consciousness；头晕 dizziness；黑朦 amaurosis；眩晕 vertigo（giddiness，dizziness）；由于气促睡不着 have a sleepless night with 8

心内科住院医师工具箱

shortness of breath；由于夜间气喘而失眠 have insomnia due to nocturnal asthma；阿-斯发作 Adams-Stokes attack；血管抑制性晕厥 vasodepressor syncope Ⅵ. 水肿的表示方法

水肿 edema；心包积液 pericardial effusion（hydropericardium）；胸水 pleural effusion；肺水肿 pulmonary edema（hydropneumonia）；踝部水肿 ankle edema；心源性水肿 cardiac（cardiogenic）edema；凹陷性 pitting；非凹陷性 nonpitting；局限性水肿 localized（local）edema；全身性水肿 generalized edema（anasarca） Ⅶ. 咳嗽与咳痰的表示方法

干咳 dry cough（nonproductive cough，hacking cough）；刺激性咳嗽 irritable cough；发作性（阵发性）咳嗽 paroxysmal cough；持续性咳嗽 cough continually；夜间咳嗽 nocturnal cough；泡沫样痰 frothy sputum；粉红色泡沫痰 frothy，pink sputum；粘痰 viscous sputum；咯血 hemoptysis

Ⅷ. 乏力和其他症状表示方法

乏力 hypodynamia；运动耐受量减退 exercise intolerance；上腹部不适 epigastric（upper abdominal）discomfort；纳差 poor appetite（loss of appetite）；活动受限 limitation of motion；嗳气 belching（eructation）；反酸 sour regurgitation；

2. Present illness（现病史）

现病史书写重点包括：（一）主诉中症状的详细描述；（二）疾病的发展过程；（三）诊疗经过；（四）目前的一般情况。

Ⅰ. 诱因

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心内科英文病历模板

无诱因下 with no inducing factors；

无明显诱因下 under no obvious predisposing causes 感冒一周后 after getting（catching）common cold for 1 week

Ⅱ. 症状出现的叙述

有……症状 suffer from/ have an attack of/ have（fell）/ begin to fell/ a feeling（sensation）of …/ complain（of）/ … sensation（feeling）in（of）…

活动时呼吸困难 dyspnea on exertion

躺下后即出现咳嗽 cough occurs soon after lying 与……有关 be associated with/ have（make）relation to …

与……无关 have（make）no relation to … 餐后加重 become worse after taking meals 站立后缓解 be relieved by standing up

随呼吸和咳嗽而加重 become more severe with breathing and cough

伴有…… be accompanied by … Ⅲ. 起病方式

暴发性起病 the onset was fulminating 骤起胸痛 an explosive onset if chest pain 突发起病 the onset was sudden

因……而突然起病 the attack is precipitated by … 突发突止 attacks began and ended abruptly 很快发生晕厥 syncope occurred rapidly 偶尔 occasionally（sporadically，accidentally） 反复胸闷心悸 recurrent（bouts of）chest discomfort and palpitation 10

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一过性发作 transitory attack 连续胸痛 chest pain continually 时重时轻 waned and waxed

时好时坏 wane and wax；hang in the balance 发作性呼吸困难 paroxysmal short of breath 持续性（间歇性） persistent（intermittent） 频发胸痛 frequent episodes of chest pain 持续不变 be steady Ⅳ. 病情变化描述

症状好转 fell better than before；take a favorable turn；take a turn for better；improve；make favorable progress；turn for the better；change for the better；be better

症状减轻 alleviate，reduce，palliate，diminish，ease（lighten），mitigate

症状消失 disappear，subside，regress，clear up，vanish，dissolve，die（fade）away，relieve

症状加重 be（make，become，get）worse（worsen）；become more severe；take a turn for the worse；be aggravated；increase in severity；take a bad turn；make（become）more serious；make（become）heavier

无变化 remain the same as …；continue without change；be identical；be alike；be similar；resemble

Ⅴ. 症状持续的时间表示 持续了2天 lasted for 2 days

已持续了一个月 have gone on for 1 month 已连续了10小时 have continued for 10 hours 平均持续了3~5小时 lasted on the average 3-5 hours 持续时间在5分钟到数小时 lasted a variable time

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from 5 minutes to several hours

大约持续半小时 lasted about half an hour 超过（不到） more than（less than） 2年以前 2 years ago

多在下午3到5时发生 usually between 3:00 p.m. and 5:00 p.m.

已有2周未发作过 be free of onsets（attacks）for 2 weeks

Ⅵ. 症状严重程度

轻度 slight，mild；中度 moderate；重度 serious，severe

Ⅶ. 症状部位的描述 A. 部位

位于 be located（situated）in（over） 疼痛位于 there is localized pain in … 在……附近 near …

局限于…… be localized to（in，over） 限于…… be limited（confined）to … B. 表示部位的介词

心尖部，表示小的部位或点 at the apex 上腹部，表示大的部位 in the upper abdomen 在左下肢，表示皮肤表面上（下）的病变 on（beneath）the left lower limb

在右肺，表示正上方的相应体表部位 over the right lung

嘴上（下）方，表示高低或上下的位置关系 above（below）the mouth

左乳皮下 under the skin of the left breast 12

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C. 转移/放射

转移到…… shift（migrate）to …

放射到…… radiate（travel，go，refer）to … 从……放射到…… radiate from … to … Ⅷ. 病程中的一般情况

一般情况尚可（一般，差） general condition is fair（ordinary，bad）

胃纳佳（差） have a good（poor）appetite

无食欲 have no（little）appetite，lose（have no）relish for one’s food，loss（lack）of appetite，loss of interest in food

食欲减退 appetite decreases（reduces，declines，falls off）

食欲增强 one’s appetite improved

保持良好食欲 retained an excellent appetite 体重增加 gain in weight

体重减轻 loss of weight（weight loss）

体重稳定不变 body weight is stable（unchanged，maintained）；weight remained stationary（steady）；weight is well maintained

睡眠障碍 somnipathy

睡眠不足 lack（want）of sleep 不易入睡 have trouble getting to sleep 容易入睡 fall into a sleep very easily 嗜睡 somnolence 失眠 have insomnia

大（小）便通畅 stool（urination）is easy and smooth（unobstructed，clear）

便秘（腹泻） constipation（diarrhea）

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心内科英文病历模板

排尿困难 difficulty in micturition

尿频（急） frequency（urgency）of micturition 尿痛 micturition pain

少尿（无尿、多尿） oliguria（anuria，polyuria） 大便失禁 fecal incontinence 小便失禁 incontinence of urine 精神不振 lassitude

精神紧张（抑郁） mental stress（depression） 精神混乱 confusion

精神失常 amentia（mental state is bad）

精神状态正常 orthophrenia（mental state is good） 体力旺盛（不足、正常） hypersthenia（hyposthenia，euthesia）

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