英文病例书写(14)

英文病例书写

；because of ) mid-chest pain of recent onset, breathlessness and

palpitations.

（2）~感

-恐惧(眩晕、恶心、寒颤)感 a sensation of fear (giddiness, nausea, chill) -异物(压迫、窒息、烧灼、寒颤)感 foreign body (oppressive, strangling,

burning, chilly) sensation (feeling)

-喉头的痒感 itching sensation in one's larynx

-模糊不舒服的感觉 vague ill feeling

-咽喉上的束紧感 a feeling of constriction in one's throat

-在咽喉右边的微痒感 a tickling feeling in the right side of the throat

-在~后头部的特殊、难堪的感觉 a peculiar, weighty feeling in the back

of one's head

-在右上腹部深处的模糊不舒适感 a vague sense of unease deep in the

right upper abdominal quadrant

ex1：她近来感觉，似有东西压在膀胱上。

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）主诉：应尽可能引用病人的话，说出现症的主要症状，经过期间和找

医师看病的原因。记述需扼要简明并避免含糊语句，常用可用

简写的方式。

ex1：从昨晚饭后，病人一直感觉寒战。

Patient has had chills after dinner since last evening.

↓

可简写为Chills since last evening.

ex2：主诉：胃肿胀已4个月。

C.C.："Swelling of the stomach" for 4 months.

ex3：2,3个月来，一做工就感觉呼吸困难和眩晕。

For 2 or 3 months, dyspnea and dizziness on work.

（4）病历的申述

-不完全可靠 be not entirely reliable

-不甚明晰 be not clearly defined

-有些模糊 be somewhat vague

-无法获得 be unobtainable

-不能申述适当的病历 can give no adequate history

-混乱不很肯定 be uncertain and confused

ex1：关于既往症，他不能提供可靠的报告。

He could not give reliable information concerning former illness.

ex2：因为他有精神激动，无法获得可靠的病历。

Because of his mental agitation, no reliable history could be obtained.