第二節(jié)心內(nèi)科常用英文病歷模板熟練地閱讀和書寫英文病歷是一名臨床醫(yī)師需要具備的基本外語技能。對英文病歷的熟練掌握對于閱讀英文文獻(xiàn)和撰寫英文論文都有很大的幫助。本章主要介紹心內(nèi)科常見疾病英文病歷的格式和基本模板。英文病歷的書寫格式大致與中文病歷相似，主要包括以下部分：Generalinformation（一般情況）Chiefcomplaint（主訴）Presentillness（現(xiàn)病史）Pasthistory（既往史）Personalhistory（個(gè)人史）Familyhistory（家族史）Physicalexamination（體格檢查）8.Investigation（輔助檢查）9.Historysummary（病史特點(diǎn)）10.Impression（印象、初步診斷）11.Signature（簽名）鑒于不同疾病的病歷之間存在共性，本章按照病歷的通用部分和心血管內(nèi)科部分逐一進(jìn)行介紹。第一部分通用部分1.Generalinformation （一般情況）這一部分包括names（姓名），age（年齡），sex（性另U）,race（民族）,nationality（國籍），address（地址和電話），occupation（職業(yè)），maritalstatus（婚姻狀況），dateofadmission（入院日期）Mateofrecord（記錄日期），complainerofhistory（供史者）和reliability（可信度）等12項(xiàng)內(nèi)容?；靖袷饺缦?Name:LiuSideAge:EightyName:LiuSideAge:EightySex:MaleRace:HanNationality:ChinaAddress:NO.35,DandongRoad,JiefangRvenue,Hankou,Hubei.Tel:857307523Dateofadmission:Aug6th,2001Dateofrecord:11Am,Aug6th,2001Complainerofhistory:patientssonandwifeReliability:ReliableOccupation:RetiredMaritalstatus:Married這一部分應(yīng)首先總結(jié)既往一般健康狀況、 Operativehistory（手術(shù)史）、Infectioushistory（傳染病史）、Allergichistory（過敏史）等，然后對各系統(tǒng)健康狀況進(jìn)行回顧，包括Respiratorysystem（呼吸系統(tǒng)）、Circulatorysystem（循環(huán)系統(tǒng)）、Alimentarysystem（消化系統(tǒng)）、Genitourinarysystem（泌尿生殖系統(tǒng)）、Hematopoieticsystem（血液系統(tǒng)）、Endocrinesystem（內(nèi)分泌系統(tǒng)）、Kineticsystem（運(yùn)動(dòng)系統(tǒng)）和Neuralsystem（神經(jīng)系統(tǒng)）基本格式示例如下：PasthistoryThepatientishealthybefore.Nohistoryofinfectivediseases.Noallergyhistoryoffoodanddrugs.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Hewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.Personalhistory（個(gè)人史）和Familyhistory（家族史）這一部分包括患者的出生和居住情況、生活環(huán)境情況（疫水疫區(qū)接觸史）、不良嗜好情況以及Obstetricalhistory（婚育史）、Menstrualhistory（月經(jīng)史）、Contraceptivehistory（避孕史）等。Familyhistory（家族史）應(yīng)包括直系親屬生存情況及家族性遺傳病史。基本格式示例如下：PersonalhistoryHewasborninWuhanonNov19th,1921andalmostalwayslivedinWuhan.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Heisamalepatient.Obstetricalhistory:NoContraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdeads.Physicalexamination（體格檢查）體格檢查部分內(nèi)容比較繁多，應(yīng)根據(jù)全身一般情況、頭頸部、胸部、腹部、四肢的順序逐一描述查體所見，其順序和格式大致同中文病歷。一般情況這一部分包括基本生命體征(體溫、心率、呼吸、血壓)、發(fā)育、營養(yǎng)、神志、體位、面容和表情、檢查能否合作、全身皮膚黏膜、淺表淋巴結(jié)等情況。示例：T36.5C,P130/min,R23/min,BP100/60mmHg.Heiswelldevelopedandmoderatelynourished.Activeposition.Hisconsciousnesswasnotclear.Hisfacewascadaverousandtheskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotfoundenlarged.各系統(tǒng)體格檢查按照從頭部到四肢的順序逐部位進(jìn)行描述， 與中文病歷大致相同。示例：HeadCranium:Hairwasblackandwhite,welldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Oralmucousmembranewasnotsmooth,andtherewereulcercanbeseen.Tonguewasinmidline.Pharynxwascongestive.Tonsilswerenotenlarged.Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.Thorax:Symmetricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof23/min.thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate150/min.Cardiacrhythmwasnotregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.Genitourinarysystem:Notexamed.Rectum:notexamedInvestigation（輔助檢查）將重要的輔助檢查結(jié)果一次記錄即可。Historysummary（病史總結(jié)）這一部分應(yīng)包括一般特點(diǎn)、主訴、既往史、體格檢查、輔助檢查等五個(gè)方面的簡要小結(jié)，主要列舉與疾病相關(guān)的情況和相關(guān)陽性結(jié)果。大致同中文病歷首次病程記錄中的病史特點(diǎn)。示例：Patientwasmale,80yearsoldUpperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours.Nospecialpasthistory.Physicalexamination:T37.5°C,P130/min,R23/min,BP100/60mmHgSuperficiallymphnodeswerenotfoundenlarged.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.Nootherpositivesigns.Investigationinformation:Blood-Rt:Hb69g/LRBC2.80T/LWBC1.1G/LPLT120G/L.ImpressionandSignature （初步診斷和簽名）在這一部分記錄對患者的初步診斷并簽署記錄者的簽名。注意在書寫格式上應(yīng)居于頁面的右側(cè)。示例：Impression:uppergastrointestinehemorrhageExsanguineshockSignature:HeLin（95-10033）第二部分心血管專業(yè)部分Chiefcomplaint（主訴）（1） Symptom+Time（癥狀+時(shí)間）Chestpainfor2hours胸痛2小時(shí)Chestdiscomfortandpalpitationofthreeday 'sdur胸悶、心悸3天Shortofbreath1monthinduration氣促1月Tow-dayhistoryofademaonthelowerlimbs雙下肢水腫2天（2） 心內(nèi)科常見癥狀I(lǐng).胸痛或不適感胸悶chestdistress;胸痛chestpain；心前區(qū)痛precardialpain;胸部不適感chestdiasomfort;胸部緊縮（壓榨）感squeezing（tightness,choking,pressing,constricting,crushing,oppressing,compressing,wiselike,heavypain）sensationofthechest;瀕死感impendingdoom；放射至頸部（下頜、上腹部、肩、左上肢）radiatingtoneck（jaw,epigastrium,shoulders,leftarm）；胸骨后痛retrosternalpain；車屯痛dullpain；WU痛twingepain/stabbing;刀割（刺）樣痛knife-likepain/piercingpain；燒灼痛burningpain;絞痛colicky（griping,cramp）pain;撕裂痛tearingpain;靜息痛restpain;持續(xù)性痛persistentpain(unremittingpain); 間歇性痛intermittentpainH.呼吸困難的表示方法呼吸困難dyspnea(difficultyinbreathing,respiratorydifficulty,shortorshortnessofbreath);氣促tachypnea(rapidorfastbreathing,acceleratedbreathing,shortofbreath);心源性呼吸困難 cardiacdyspnea；端坐呼吸orthopnea；夜間陣發(fā)性呼吸困難 paroxysmalnocturnaldyspnea,PND;靜息時(shí)呼吸困難 dyspneaatrest活動(dòng)時(shí)呼吸困難dyspneaonexertion； 臥位時(shí)呼吸困難dyspneaonlyingdownm.G^的表示方法心慌flustered；心悸palpitation；心動(dòng)過速tachycardia；兒、動(dòng)過緩bradycardia；兒、律不齊arhycardiaIV.發(fā)鄒■的表示方法發(fā)第cyanosis；先天性發(fā)第congenitalcyanosis；中樞性central；周圍性peripheral；混合性mixed；指端發(fā)第acrocyanosis意識障礙和睡眠的表示方法意識障礙disturbanceofconsciousness；頭暈dizziness；黑朦amaurosis；目玄暈vertigo(giddiness,dizziness)；由于氣促睡不著haveasleeplessnightwithshortnessofbreath；由于夜間氣喘而失眠h(yuǎn)aveinsomniaduetonocturnalasthma；阿-斯發(fā)作Adams-Stokesattack；血管抑制性暈厥vasodepressorsyncope水腫的表示方法水腫edema；心包積液pericardialeffusion(hydropericardium)；胸水pleuraleffusion；肺水月中pulmonaryedema(hydropneumonia);踝部水月中 ankleedema；心源性水月中cardiac(cardiogenic)edema；凹陷性pitting；非凹陷性nonpitting;局限性水腫localized(local)edema；全身性水月中g(shù)eneralizededema(anasarca)叫.咳嗽與咳痰的表示方法干咳drycough(nonproductivecough,hackingcough);刺激性咳嗽irritablecough;發(fā)作性(陣發(fā)性)咳嗽paroxysmalcough;持續(xù)性咳嗽coughcontinually；夜間咳嗽nocturnalcough；泡沫樣痰frothysputum；粉紅色泡沫痰frothy,pinksputum；粘痰viscoussputum；咯血hemoptysisvm.乏力和其他癥狀表示方法之力hypodynamia；運(yùn)動(dòng)而寸受量減退exerciseintolerance;上腹部不適 epigastric(upperabdominal)discomfort;納差poorappetite(lossofappetite)；活動(dòng)受限limitationofmotion；曖氣belching(eructation)；反酸sourregurgitation；Presentillness(現(xiàn)病史)現(xiàn)病史書寫重點(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。I.誘因無誘因下withnoinducingfactors；無明顯誘因下undernoobviouspredisposingcauses感冒一周后aftergetting(catching)commoncoldfor1weekn.癥狀出現(xiàn)的敘述有...癥狀sufferfrom/haveanattackof/have(fell)/begintofell/afeeling(sensation)of??-/complainof)/-sensation(feeling)in(of)??-活動(dòng)時(shí)呼吸困難dyspneaonexertion躺下后即出現(xiàn)咳嗽coughoccurssoonafterlying與...有關(guān)beassociatedwith/have(make)relationto??-與...無關(guān)have(make)norelationto??-餐后力口重becomeworseaftertakingmeals站立后緩解berelievedbystandingup隨呼吸和咳嗽而加重becomemoreseverewithbreathingandcough伴有...beaccompaniedby??HI.起病方式暴發(fā)性起病theonsetwasfulminating驟起胸痛anexplosiveonsetifchestpain突發(fā)起病theonsetwassudden因...而突然起病theattackisprecipitatedby突發(fā)突止attacksbeganandendedabruptly彳艮快發(fā)生暈厥syncopeoccurredrapidly偶爾occasionally(sporadically,accidentally)反復(fù)胸悶心悸recurrent(boutsof)chestdiscomfortandpalpitation一過性發(fā)作transitoryattack連續(xù)胸痛chestpaincontinually時(shí)重時(shí)輕wanedandwaxed時(shí)好時(shí)壞waneandwax；hanginthebalance發(fā)作性呼吸困難paroxysmalshortofbreath持續(xù)性(間歇性)persistent(intermittent)頻發(fā)胸痛frequentepisodesofchestpain持續(xù)不變besteadyIV.病情變化描述癥狀好轉(zhuǎn)fellbetterthanbefore；takeafavorableturn；takeaturnforbetter；improve；makefavorableprogress；turnforthebetter；changeforthebetter;bebetter癥狀減輕alleviate,reduce,palliate,diminish,ease(lighten),mitigate癥狀消失disappear,subside,regress,clearup,vanish,dissolve,die(fade)away,relieve癥狀力口重be(make,become,get)worse(worsen)；becomemoresevere；takeaturnfortheworse；beaggravated；increaseinseverity；takeabadturn；make(become)moreserious；make(become)heavier無變化remainthesameas?…；continuewithoutchange；beidentical；bealike；besimilar；resemble癥狀持續(xù)的時(shí)間表示持續(xù)了2天lastedfor2days已持續(xù)了一個(gè)月havegoneonfor1month已連續(xù)了10小時(shí)havecontinuedfor10hours平均持續(xù)了3~5小時(shí)lastedontheaverage3-5hours持續(xù)時(shí)間在5分鐘到數(shù)小時(shí)lastedavariabletimefrom5minutestoseveralhours大約持續(xù)半小時(shí)lastedabouthalfanhour超過(不至V)morethan(lessthan)2年以刖2yearsago多在下午3至U5時(shí)發(fā)生usuallybetween3:00p.m.and5:00p.m.已有2周未發(fā)作過befreeofonsets(attacks)for2weeks癥狀嚴(yán)重程度輕度slight,mild；中度moderate；重度serious,severe叫.癥狀部位的描述部位位于belocated(situated)in(over)疼痛位于thereislocalizedpainin??-在...附近near??-局限于...belocalizedto(in,over)限于...belimited(confined)to??-表示部位的介詞心尖部，表示小的部位或點(diǎn) attheapex上腹部，表示大的部位 intheupperabdomen在左下肢，表示皮膚表面上(下)的病變on(beneath)theleftlowerlimb在右肺，表示正上方的相應(yīng)體表部位 overtherightlung嘴上(下)方，表