这里是最全的英文病历书写要点及常用表达总结，谁错过谁后悔

小白老师说：整理这个真的蛮累的，费了小白老师好多的时间、咖啡和洪荒之力。不过，任何当过老师的人都知道，教就是最好的学习方式，我自己也是收获满满。

Case History

**In-Patient Case History 住院病历
**

Items of Case History

1. General Data, Biographical Data 一般项目

2. Chief Complaints (C. C.) 主诉

3. Present Illness (P. I.) 现病史

4. Past (Medical) History (P. H.) 既往病史

5. Personal History (Per. H.) / Social History 个人史 / 社会史

6. Family History (F. H.) 家族史

7. Medications 曾用药物

8. Allergies 过敏史

9. System Review, Review of Systems 系统回顾

10. Physical Examination (P. E.) 体格检查 / 查体

11. Laboratory Data 实验室与其他检查

12. Impression (Imp.) (Diagnosis) 诊断

13. Hospital Course 住院治疗情况记录

14. Discharge Instructions / Recommendations 出院医嘱

15. Discharge Medications 出院后用药

General Data, Biographical Data 一般项目

Reliability 病历可靠性

Reliable 可靠

Not Entirely 不完全可靠

Not Clearly Defined 不够准确

Confused and Uncertain 混乱不清

Unobtainable 无法获得

Supplier / Complainer of History 供史者/病史陈述者

Patient / Husband / Wife/ Father / Mother / Colleague / Neighbor

Chief Complaints (C. C.) 主诉

1) Common expressions

① symptom + since + time (时间点)

② symptom + for + time (时间段)

③ symptom + of + time (时间段名词所有格) + duration

④ symptom + time (时间段) + in duration

⑤ time (时间段合成词) + history + of + symptom

Complete sentence 完整的句子应该写成:

The duration of +symptom+was/ has been+time(时间段)

2) Common sentence patterns for chief complaints

① …was admitted

… was seen with a chief complaint of…

② …complain chiefly of…

③ …presented / entered with / came to the office with a chief complaint of

Example

主诉：患者是一个48岁的妇女。入院主诉，6个月以来，出力后心悸和呼吸困难。

CHIEF COMPLAINT: The patient is a 48-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months.

History of Present Illness 现病史

1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型

① start having 开始有……的症状

② begin having episodes of… 开始发生……的症状/疾病

③ become… 变得……

④ notice (perceive, note, recognize…) + 症状 / 疾病

⑤ have… 有……症状 / 疾病

⑥ have abrupt / sudden / explosive onset of… 突然患……

⑦ have episode of…

have attack of… 患……

⑧ develop + disease 出现 / 有了……症状 / 疾病

⑨ …are / is the prodrome of… ……的前驱症状

2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型

① begin (occur, start…) + time 从……开始

② date (go back) to + time 可追溯到……

③ be present + time 在/从……已存在

④ be preceded by… 在……之前已有

⑤ be followed by… 在……之后紧接着发生

⑥ be accompanied by… / coincide with… 与……同时发生

⑦ be (not) related to… / have (no) correlation with… 与……有（无）关

3) Illness’ improving and worsening 表达疾病的好转与恶化

① last + time 持续……时间

② take a bad turn

take a turn for the worse

be aggravated / exacerbated

become worse 恶化

③ take a good turn

take a turn for the better

improve 好转

④ be aggravated / abated / alleviated by… 因……而加剧 / 减轻

⑤ remain the same / unchanged 无变化

⑥ be (not) improved after treatment with…经用……治疗而（无）好转

⑦ (The symptom) cease / clean up / disappear / subside 症状消失 / 减退

4) No symptoms 没发生……症状、疾病

① … without / with no / free of… (symptoms)

② There be no history of…

…have no history of…

③ (The patient) denies…

④ (The patient) noted no…

⑤ (The patient) was not found to be…

5) Description of main symptoms 描述主要症状

① …assume the character of

be characterized by…

② …have / present / develop / show / manifest the symptoms of…

Past (Medical) History (P. H.) 既往病史

Common expressions

① had been sound / well until;

had enjoyed good health until… 在……前一直健康

② be apt / liable / subject to…

tend to have… 易患……

③ …was admitted to hospital for…

…was hospitalized for… 曾因……而住院

④…had (some illness) with recovery after… 曾有（疾病），因…痊愈

⑤ …was diagnosed as… 诊断为……

…was suspicious of… 疑为……

⑥ …was exposed to (toxic substances) …

had breathed (poisoning gases) 接触/吸入

⑦ …was inoculated against…接种过……

⑧ …was discharged / dismissed from hospital…

…was out of hospital… 出院

Personal History (Per. H.) / Social History 个人史 / 社会史

Characteristics of language

Declarative sentences and elliptical sentences are usually used, and present tense, past tense and past perfect tense are adopted.

Family History (F. H.) 家族史

Common expressions

① …be living and well

…be in good health

…be well with no evidence of (illness) 健在

② (There is) No family history of (disease).

(There was) No (disease) in one’s family. 无（病）家族史

③ There was no case of (disease) in his / her family.

No one in his/her family experienced (disease) 家族成员未曾患过……

④ Family history showed / revealed… 家族史显示……

⑤ There was a familial/hereditary tendency to…

There was a strong family history of…

There was a high incidence of…in the family. 家族有……倾向 / 发病率

⑥ There was a high prevalence of…in the family 家族中……患病率高

⑦ Positive for (some disease) in (some one). 曾患过……

⑧ …as a family characteristic. 家族特点

⑨ FH: Noncontributory 家族史无意义

Allergies 过敏史

Common expressions 常用表达

① NKDA (no known drug allergies) 无过敏史

② allergy, allergic, hypersensitive, hypersensitivity 过敏

③ sensitive, sensitivity, sensible, sensibility 敏感

④ allergic reaction 过敏反应

⑤ be allergic to… 对……过敏

⑥ be sensible to… 对……敏感

⑦ have no history of allergy to…;

have no history of…sensibility 对……有（无）过敏史

⑧ have an allergic diathesis 具有过敏体质

⑨ have no allergic reaction to any drugs 对用过的药物无过敏反应

⑩ show sensibility to…(e.g. house dust) 对……（如室内灰尘）过敏

Physical Examination (P. E.) 体格检查，查体

1. Physical data 一般资料

Physical signs 生理指标

2. General appearance 一般情况或全身状态
3. Head, eyes, ear, nose and throat (HEENT) 头，眼，耳鼻喉
4. Chest, heart and lungs 胸部与心肺
5. Abdomen 腹部
6. Extremities 四肢
7. Nervous system, neurological (CNS / Neuro) 神经系统
8. Musculoskeletal 骨骼肌肉系统
9. Genitourinary 泌尿生殖系统

Physical data / physical signs 一般资料 / 生理指标

① Temperature (T.) 体温

position: oral temperature 口温

axillary temperature 腋温

rectal temperature 肛温

unit: Celsius, ℃; Fahrenheit, ℉

Format: T 38 ℃ (or 100.4 ℉)

② Pulse (P.) 脉搏

Format: P 80/min (or P80)

Pattern: Pulse 80 per minute.

The pulse numbered/beat/measured 80/min.

③ Respiration/ Respiratory Rate (R.) 呼吸

Format: R 20/min

Common expressions:

The respirations are 21 per minute. 呼吸每分钟21次。

④ Blood Pressure (B. P.) 血压

Format: BP 16/10.5 kpa 血压16/10.5千帕

BP 150/95 mmHg 血压150/95毫米汞柱

BP stabilizes at…kpa (mmHg) 血压稳定在……千帕（毫米汞柱）

BP fluctuates / ranges between…and… 血压波动在……与……之间

rise / drop from…to… 由……升 / 降到……

⑤ Heart Rate (H. R.) 心率

Format: HR 80 / min
Heart Rate: 80 per minute 心率每分钟80次

⑥ Cardiac Rhythm 心律

General appearance 一般情况或全身状态

① Height (Ht.)

② Body Weight (BW/Wt.)

③ complexion 面色

appearance 面容

expression 面部表情

④ mental state 神态

consciousness 意识

senses 感觉

⑤ nutrition 营养状况

well-nourished 营养良好

moderately nourished 营养中等

ill-nourished / malnourished / malnutrition / poorly-nourished / under-nourished 营养不良

fat / obese 肥胖

lean / emaciated / thin / underweight 消瘦

Laboratory Data 实验室检查资料

Blood test

Urinalysis

Electrocardiogram (ECG)

Electroencephalogram (EEG)

X-ray examination and X-ray slides X光检查及X光片

Computerized X-ray tomography (CT) 计算机X线断层扫描

Magnetic resonance imaging (MRI)

Nuclear magnetic resonance imaging (NMRI) 磁共振成像

Other lab data 其他检验资料

**Out-Patient Case History 门诊病历
**

Items of Case History

1. General Data, Biographical Data 一般项目

2. Chief Complaints (C. C.) 主诉

3. Present Illness (P. I.) 现病史

(4. Past (Medical) History (P. H.) 既往病史)

5. Physical Examination (P. E.) 体格检查，查体

6. Impression (Imp.) (Diagnosis) 诊断

7. Treatment 治疗