-
英文病历全攻略
一、主要調查項目：
1.
主訴
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.
現症歷
present
illness
：
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
and
strength,
sleep,
bowel
movement,
frequency
of
urination,
menstruation, etc.
3.
既往歷
past
history
：
1)former
places
of
residence,
previous
stage
of
health(
健壯的
robust
，纖弱的
delicate),
experience with
similar disease, immunity to infectious
disease
2)previous
illness
：麻疹
measles,
腮腺炎
mumps,
水痘
chicken-pox,
百日咳
pertussis,
流行性
感冒
influenza,
猩紅熱
scarlet fever,
白喉
diphtheria
，
傷寒<
/p>
typhoid fever,
支氣管炎
bronchitis,
肺
炎
pneumonia
，腦炎
ence
phalitis,
腦膜炎
meningitis
，破傷風
tetanus,
小兒麻痺
poliomyelitis,
赤痢
dysenter
y
，
霍亂
cholera,
胸膜炎
pleurisy,
天花
small-pox
，
瘧疾
m
alaria,
結核病
tuberculosis
，
黃疸病
jaundice
，過敏性反應
allergy,etc
3)venereal
disease
：
specific 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.
家族歷
family
history
：
family tendency,
presence of hereditary disorders, cancer,
tuberculosis,
mental
disorder
and
nervous
affection,
rheumatism,
diabetes,
hypertension,
cerebral
vascular
accident,
hemophilia,
syphilis,
tumor,
epilespsy,
allergy,
contact
with
diseased
individuals,
relationship
of
patient’s
childhood
and
adult
life,
age,
health
condition,
and
cause
of
death
of
parents, grandparents,
self , spouse, siblings , or relatives.
5.
個人歷
personal
history
：
1)Social
history
：
fears, metal status,
education, financial condition, number of
dependents, family
harmony or fractious
, hygienic condition at home
2)Marital
history
：
duration of
marriage, 1st or 2nd marriage, age and death of
spouse and children ,
cause and age at
time of death, number of children , pregnancies,
流產次數
miscarriages,
死產數
stillbirths
3)occupational
history
：
duration
of
employment,
past
work,
exact
nature
of
work,
exposure
to
occupational hazards, whether work is
satisfactory or not.
4)Habits
：
alcohol,
tobacco, narcotic, coffee, tea, appetite, food
habits, regularity of meals, rapidity
of eating , bowel movements, sleep,
exercise, interests, etc.
6.
系統檢查
system
review
：
1)General
：
nutrition, fever, night
sweats, tremor, weight gain or loss, weakness,
allergy.
2)Skin
：蕁蔴疹
hives,
rash, eczema
3)Head
：
trauma,
headache, loss of hair
4)Eyes
：
vision,
pain glasses diplopia.
5)Ears
：
pain,
discharge, deafness, tinnitus.
< br>6)Nose
：
obstruction,
discharge, epistaxis, rhinitis.
7)Mouth
：
teeth,
lips, gums, tongue, disturbance in
taste.
8)Throat.
：
sore
throat, tonsillitis,
膿性扁桃腺炎
quinsy,
dysphagia
9)Neck
：
adenitis,
goiter , rigidity
10)Cardior
espiratory
：
palpitation,
tachycardia,
blood
pressure,
chest
pain,
dyspnea,
cough
,
hemoptysis , seasonal cold,
expectoration.
11)Gastrointe
stinal
：
appetite,
nausea,
vomiting,
distress(before
or
after
meals),
melena,
colic,
jaundice,
fullness,
hernia,
hemorrhoid,
constipation,
diarrhea,
frequency
of
bowel
movement
,
heartburn, idiosyncrasies, relation of
symptoms to eating, type and quantity of
food
12)Genito-
urinary
：
dysuria, urinary
frequency, dribbling , hematuria, pyuria, nocturia
and volume,
enuresis,
incontinence,
sores
about
external
genitalia,
symptoms
suggestive
of
syphilis(mucous
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 headache
13)Neuromuscular
：神經過敏
ner
vousness,
emotional
stress,
weakness,
muscle
or
joint
pains,
convulsion, numbness, neuralgia,
anesthesia, muscular atrophies or dysatrophies,
deformities.
二、病歷與時態
1
．現症歷
(present
illness)
：
1)A.
現在式：表示一般的真理、職業、人格、習慣和現在的事實、動作或狀態。
例
1
：
Sedentary habits often interfere with
health
例
2
：
He
is mentally deranged and disoriented as to time,
place, and person
例
3
：
He
gets up at 6 every morning.
B.
現在進行式（
Be+ pres.
p.
）表示現在某動作正在進行中。
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.
<
/p>
C.
表「經常的習慣」也用進行式，通常與
always, constantly
等副詞連用。
例
1
：
He
is always taking a nap in class.
例
2
：
He
is constantly forgetting
peoples
’
names.
例
3
：
He
is for ever complaining of headaches.
D.
通常不用進行式的動詞。
a)
不隨意動詞
( Verbs of
involuntary actions)
：
-
知覺
(
perception)
：
feel, hear,
notice, see, smell
等。
例
1
：
Whenever
he has a cold, he can neither taste nor
smell.
-
知識
(knowledge)
：
believe,
(dis)agree,
doubt,
find,
forget,
know,
mind,
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)
表示繼續狀態的動詞
(
Verbs of continuous
state)
：表示存在、所有等動
詞：
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.
現在完成式
( Have+
p.p)
a)
表示動作的完了
(completion of an
action)
或其結果的現在狀態
(present
state of things)
：
例
1
：
The
patient has passed the crisis. = The patient is
out of danger now.
例
2
：
He
has caught cold. = He has a cold now.
註：常用的連用副詞為：
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。
比較：過去式僅表示過去的動作狀態；現在完成式則以表示現在為主。
< br>
例
1
：
He
had no appetite for food. (
過去式
)
→
表示過去某時有過食慾不振
例
2
：
Lat
ely he had had no appetite for food. (
現
在完成式
)
→
表示現在仍然胃口不佳。
b)
表示截至現在為止的經驗
(
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.
註：
表示經驗時，
常用的副詞為：
ever, before, once, many
times, (very) often, seldom, sometimes,
in one
’
s time
等副詞。比較：同一動詞有時表示完了，有時表示經驗，視其所連用的副詞而
決定。
例
1
：
He
has just undergone a nephrectomy.
→
表示動作完了。
例
2
：
He
has undergone a nephrectomy
once.
→
表示經驗。
c)
表示截至現在為止的動作或狀態的繼續（
co
ntinuance
）
例
1
：
He
has been deaf in the left ear since the age of 18
and has experienced slight dizziness on
stooping.
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.
註：常用的連用副詞為：
since, always,
from, for, these, how long
？
B.
現在完成進行式
( Have
been +~ing)
a)
表示以
前開始的動作繼續到現在的狀態：
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.
<
/p>
b)
表示「習慣」
：
例
1
：
The
patient has been smoking excessively.
例
2
：
She
has been chewing a wad of bubble gum all
day.
註：常用的連用副詞為：
since, for, how
long
？
,these, form,
always
等。
比較：
例
1
：
He
has been learning medicine for 5 years.
(
繼續
)
例
2
：
He
has learned medicine for 5 years.
(
經驗
)
2
．既往歷
(past
history)
：大半用過去式，但發生過去某一定時間以前者，宜用過去
完成式；
如果疾病發生的前後關係甚明顯，或以年代順序記載時，仍可用過去式。
1)A.
過去式：用以表示過去的動作、狀
態、習慣等且與現在的情形毫無關聯。
a)
發生於過去某時者：
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 exertional dyspnea.
例
4
：
Before therapy,
she was unable to swallow anything but small sips
of water.
b)
過去某時以後的狀態：
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 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 ensuing 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.
註
1
：
過去式常用的連用副詞：
ag
o, last night, yesterday, the day before
yesterday, the other day,
this morning
, just now
等。
註
2
：現在完成和過去兩者都可用的連用副詞：
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.
表示過去的習慣時，須用
used
to
,
was
(were)
accustomed
to
~
或
had
the habit
to
~
等。用
would
來表示過去的習慣時，大抵
與
often,
sometimes
等副詞連用。
例
1
：
He
used to work far into the night.
例
2
：
He
would sometimes come home drunk, and beat his
wife.
C.
過去進行式
( Be
動詞的過去式
+ pres.
p.)
：表示在過去某一時間正在進行
的動作：
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 large amounts of purulent sputum at
that time.
D.
過去完成式
( Had + p.
p.)
：表示截至過去某一時間為止的動作的完了、經驗、繼續等。
a)
完了
(
completion)
：
例
1
：
The
patient had already expired when he
came.
例
2
：
By
that time he had immunized against
smallpox.
連用副詞：
already, by that time,
(not) yet, only just
等。
b)
經驗
(experience)
：
例
1
< br>：
Till then he had never seen so-
called bone-setter.
例
2
：
He
could not repeat what he had said
before.
c)
繼續
(continuance)
：
例
1
：
He
had long been ill in bed.
例
2
：
He
had been ill in bed for a long time.
E.
過去完成進行式
(Had
been + pres.
p.)
：表示繼續過去某一時間的動作。
例
1
：
Up
to that time, he had been drinking mush
wine.
例
2
：
Due
to her increasing constipation, she had been
taking laxatives daily for one year before
admission.
比較：
例
1
：
I
was sleeping when he came.
(
過去進行式
)
例
2
：
I
had been sleeping for an hour before he
came.(
過去完成進行式
)
三、家族歷
1.
家族無
~
病：
< br>例
1
：
There is no
family history of anemia or other relevant
disorders.
例
2
：
The
family history did not reveal the occurrence of
any congenital anormaly.
2.
家族歷無異狀：
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
Darier
’
s
disease,
was
no
contributory.
例
4
：
There is nothing
important in his 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
Hodgkin
’
s
disease.
例
2
：
Family history showed chronic
gastrointestinal symptoms in a maternal
cousin.
5.
家族有
~
傾向：
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.
過敏：
例
1
：
He
had no history of penicillin sensibility, however,
he once noted petechiae after taking
aspirin.
例
2
：
No
asthma, hives or any idiosyncrasy to
foods.
7.
因
~
而死：
例
1
：
His
father
’
s death was
coincidental with the
patient
’
s
illness.
例
2
：
His
eldest brother died of pneumonia at the age of 28
in the preantiboitic era.
四、個人歷
1.
吸煙：
例
1
：
History
revealed that he started smoking 10 years before,
at the age of 23, and has smoked
ever
since.
At
first
he
smoked
only
a
few
cigarettes
a
day
but
gradually
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
the past 7 years.
2.
飲酒：
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.
飲食：
例
1
：
The
boy never ate any fresh fruits 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
patient
’
s 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
：
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.<
/p>
其他
(
衛生、習慣等
)
：
例
1
：
He
spent 3 months visiting Taipei in early 1960 and
denied travel outside of Taiwan after that
time.
例
2
：
The
pt. related that she has always lived in Peitou
expect for 8 months during 1958~1959
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 Taitung
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
spending 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 lived, and he was
well
satisfied with his present occupation.
五、既往歷
Past History
(1)
他一直很健康，到
1960
年
10
月，才慢慢地開始有咳嗽和膿痰。<
/p>
He
had
enjoyed
good
health
until
Oct.
1960,
when
he
gradually
developed
cough
and
purulent
sputum.
※到某時一直健康
-
幾乎未生病
be barely ever sick
ex1
：
He had been
well until Nov. 1960, at which time he was found
to have diabetes mellitus.
ex2
：
He was
apparently healthy most of his life, and did not
consult a physician until his present
illness.
(2)
以前他沒有患過任何病，在幼小時所做的一般免疫，並無不良反應。
He
had
no
illnessnes
of
any
kind
before
and
received
routine
immunizations
at
an
early
age
without ill effects.
※未曾患過病
ex1
：
He denied
experiencing episode of coughing at any time in
his life.
ex2
：
He denied any
history of prior cardiovascular symptoms before
onset of the present illness.
(3)
他曾患過通常的小兒期疾病和肺炎一次，這些病都順利痊癒。
He had the usual childhood
diseases plus one bout of pneumonia from which he
made uneventful
recoveries.
※生過病
-
患病
suffer from
；
have
an attack of
；
be attacked
by
-
在童年時代患過麻疹，但無合
併症發生
have measles during
childhood without complications
-
一起身就會頭暈
experience light-headed on sitting up
-
患嚴重的喘息性支氣管炎
contract severe asthmatic
bronchitis
ex1
：
He had a
lunatic tendency 4 years ago.
ex2
：
He has been a
known diabetic since 24 years of age.
<
/p>
※除
~
病外未患過病
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
by
high
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 illness
ex1
：
Although
he
was
subject
to
joint
pains
in
his
childhood,
he
gave
no
definite
history
of
rheumatic
fever.
ex2
：
She was
susceptible to car sickness, a tendency which had
been less pronounced in the past
year.
(4)
< br>他有在
22
歲患過肺炎的病歷。
He has a history of pneumonia diagnosed
at the age of 22.
※診斷
-
診斷
diagnose (the case as)
；
establish (make) a
diagnosis
-
誤診
make a wrong diagnosis
；
misdiagnosis
ex1
：
He has a
history of being diagnosed as pneumonia 4 years
ago.
ex2
：
He states
that a diagnosis of pneumonia was made 4 years
ago.
※「診斷」記載例
ex1
：
Diagnosis
：
senile paranoid
ex2
：
Diarrhea and
vomiting of undertermined etiology.
ex3
：
Malignant
gastric ulcer, as much as could be
observed.
※診斷書
ex1
：
This
certifies that the above named patient suffered
from the disease
stated
above.
ex2
：
This is to
certify that the said patient is seriously sick
with liver atrophy.
It is
recommended that he should be confined to hospital
for good care
and treatment
for a period of one month.
(
5)
他於
1952
年
< br>10
月
16
日，因肺結核接受部
分胸廓成形術，而住了院。
He was admitted
on Oct. 16, 1952 to undergo a partial
thoracoplasty for pulmonary
tuberculosis.
※年月日
-
在
8
月
3
日黃
昏
on the evening of Aug.
3
-
去年
1
1
月
in Nov.
last
；
last Nov.
-
在前幾個月當中
during the past couple of
months
-
在上月初
(
月中、月底
) at the
beginning (middle, end) of last month
-
每隔一天
every other
day
；
on alternate
days
；
every two
days
-
每隔二天
at intervals of 2
days
；
every 3rd
day
-
連續
5
天
for 5
consecutive days
-
幾乎一個月
for nearly a month
-
足足的一個月
for a full month
-
期間不詳
for an unknown length of
time
-
期間不明確
for an indefinite period
-
次
2
夜
the 2 succeeding
nights
-
前一夜
the preceding (previous)
night
※住院
-
住院
enter (be admitted to )
hospital
；
entering (admission
to ) hospital
；
go (be taken )
to hospital
-
住院時
at the time of one's admission to the
hospital
-10
年前因治療肺炎而住院
be hospitalized 10 years ago for
treatment of pneumonia
※出院
-
出院
leave hospital
；
be
out of hospital
；
be discharged (dismissed) from
hospital
（
6
）在
1960
年他患了胃病，在醫院治療
16
天後痊癒。
In
1960 he experienced stomach trouble from which he
recovered completely after being treated in
a hospital for 16 days.
※治療
-
徹底醫治
cure (a disease) completely (radically)
；
effect a radical
cure
-
作許多種治療
try many treatments (for)
-
忽視腫瘤，並且不接受治療
ignore the tumor and refuse
treatment
-
在家裡接受治療
have domiciliary treatment
-
述說過去一再使用盤尼西林治療淋病
give a history of repeated treatments
with penicillin for
gono in the
past.
-
自醫
try (doctor)
oneself
；
try home
treatment
※受
~
治療
-
服用抗高血壓藥劑
receive antihypertensive
drugs
-
使
~
服抗結刻劑
put one
on antituberculosis drugs before one goes
surgery
-
替
~
打一支盤尼西林
give
one a shot of penicillin
-
經過順利
have an uncomplicated course
-
開刀後經過順利、
滿意、
不順、
(
不
)
良
postoperative course
was uneventful,satisfactory, stormy,
(un)favorable -become
convalescent
ex1
：
He did not
receive any specific therapy but was treated
symptomatically.
ex2
：
Past
history
revealed
an
episode
of
gonorrhea
in
1957
which
was
successfully
treated
by
antibiotics.
六、現症歷
Present
Illness
（
1
）他在
1960
年
9
月生了病；疲勞漸漸加重，週身不適，並且體重減輕。
He became ill in Sept. 1960, with
gradually increasing fatigue, general malaise and
loss of weight.
※疾病的發生
-
開始頭痛
started having the headaches
-
開始發生紫紺
began having episodes of
cyanosis
-
開始感覺疲勞
began feeling tired
-
變成稍一用力即會喘息
became breathless on the least
exertion
-
發覺開始過度疲勞
noted the onset of excessive
fatigue
-
晚餐時飲酒差不多一定會引起發作
a supper drink almost invariably
provokes an attack
-
不能恢復以前的那種活力
fail to regain one's previous vitality
and vigor
-
開始覺得比以前更加容易疲倦
began to fell more easily
fatigued
ex1:The disease
began (occurred started) 3 months ago. It
progressed , slowly but steadily until
today.
ex2: In
the spring of 1958 he first noticed (noted;
perceived; recognized) easy
fatiguability.
※初發病型
ex1: He
became increasingly subject to fits of
temper.
ex2: He suddenly
developed weakness in the right leg.
（
2
）她的膀胱過敏症消失，但在
1960
年秋天復發。
Her symptoms of bladder irritability
subsided, but recurred in the autumn of
1960.
※病徵
-
有疼痛和已述的症狀
pain plus the symptoms already
mentioned
-
想把症狀和<
/p>
~
關連起來
attempt to correlated symptoms
with~
-
症狀自然消退
symptoms spontaneously
regressed
-
症狀消失
(
並未緩和
) symptoms
disappeared (did not abate)
-
症狀忽緩忽急
symptoms waxed and waned from time to
time
-
不留意症狀
give the symptoms no concern
-
忽略
(
不理
)
症狀
disregard (dismiss) symptoms
-
對症狀不甚留意
do not pay much attention to the
symptoms
-
對孩子們顯得不關心、冷淡
one appeared uninterested and
uninformed about one's children
-
嘔吐是
~
發病的前驅症狀<
/p>
vomiting heralded the onset
of one's symptoms
-~
的病有傷寒的樣子
one's illness assumed the character of
typhus
-
再發（
have a)
relapse
；
recur;
recurrence
-
疾病無再發徵象
no evidence of recurrent
disease
-
同一症候再發
the return of the same
symptoms
ex1: He had
(presented; developed; showed; manifested) mild
symptoms of diphtheria.
ex2:
There have been concurrent heartburn and
eructation.
※無
~
症狀
ex1: The carious tooth has persisted
for years without clinical symptoms.
ex2: He continued remarkably free of
symptoms except for aural discharge until Nov.
1961.
（
3
）他記得一年前，在同一季節裡，有過一次同樣的發作。
He remembered a similar attack a year
before in the same season.
※發作
-
一時性眩暈
transitory attacks of
dizziness
-
發作不規則
attacks are variable
-
發作變了型態
the attacks changed pattern
-
患急性關節炎
have acute attacks of
arthritis
-
發作多半在夜間發生
attacks occurred chiefly at
night
-
患
2
次肺炎
had 2
episodes of pneumonia
-
發生癲癇樣的發作
developed seizures of an epiletic
nature
-
發作前後覺得舒適
feel well between attacks
-
平均繼續了
3~4
分鐘
lasted on average 3 to 4
minutes
-
一年來沒有發作
have been free of attacks for one
year
-
發作停止
(
消失，完全消失
)
了
attacks ceased ( subsided,
clear up completely)
ex1: A
similar attack appeared in the following morning.
It ran the same course as the first
one.
ex2: The most recent
episode occurred approximately one month before
his first visit to the clinic.
※發作時間
-B
隨
A A is
followed by B : B follows A
-A
與
B
同時發生
A is associated with B
-
和
~
有關係
have (make) relation
to~
-
和
~
不相關
have (make)
no relation to~
-
似乎與姿勢、咳嗽、過度用力無關
appeared unrelated to position,
coughing,or straining.
ex1:
The
attacks
were
preceded
by
3
or
4
hour
prodromes
of
nausea,
abdominal
distention,
diarrhea
or
constipation,
followed
by
5
to
6
hour
period
of
cramping
abdominal
pain
and
bile-
stained vomiting, terminated by transient
diarrhea.
ex2: The pain was
described as being of a cramping nature and
sometimes appeared to be related
to the
ingestion of cold water or milk.
（
4
）每天服用
pyraz
inamide 4
次，每次
75mg.
後，咳嗽減少，痰亦減半，熱度
也降低。
With
pyrazinamide, 75 mg. 4 times daily, there was
improvement of cough, a 50 per cent decline
in sputum, and a reduction of
fever.
※症狀的減輕和消失
-
轉佳
take a favorable turn take a turn for
the better improve
-
顯著減輕
decrease drastically
(markedly)
ex1:
Such
attacks
usually
subside
promptly
with
rest,
in
an
hour
or
so
,
sometimes
in
a
few
minutes.
ex2: The
swelling of the legs disappeared within about a
week.
（
5
）疼痛發生於飯後，便秘發生後，疼痛更加厲害，期間也較長。
The
pain
came
on
after
meals
and
became
more
severe
and
lasted
longer
with
the
onset
of
constipation.
※症狀的惡化
-
惡化
take a bad turn take a turn for the
worse; be aggravated (exacerbated)
-
顯著地惡化
became noticeably worse
-
漸趨顯著
became increasingly apparent
-
黃疸總是惡化
have frequent exacerbations of
jaundice
-
病入膏肓
one's case is incorrigible
-
病狀時癒時犯
one's illness hangs in the
balance
ex1: During the last
6 weeks he has observed progressive shortness of
breath on exertion.
ex2: The
pain was aggravated by exercise and alleviated
somewhat by lying down.
（
6
）他的一般情形，一直沒有變化。
His general condition continued without
change.
※症狀無變化
ex1: He remained about the same a
yesterday.
ex2: His headache
has persisted (continued) to date ( the present).
Exercise1
1.
家族歷無先天性疾病。
2.
據他說，他家裡沒有人患與此相同的病。
3.
家族歷無特別記載事項。
4.
他有出血傾向。
5.
從家族歷看來，母方有血友病的遺傳。
6.
他出生於健康而無精神疾遺傳的家庭。
7.
他父親的死因不明。
8.
他在
28
歲時，死於
肺結核。
9.
他在發病後
5
天就死了。
10.<
/p>
他在清晨
1
點
2
5
分去世。
1.
a)The family history revealed
(disclosed, showed, indicated) no congenital
disease.
b)No F.H. of
congenital disease was elicited
(present).
c)There was no
history of congenital disease in the
family.
d)The family had no
history of congenital disease.
e)There was nothing in the F.H.
suggestive of (to suggest) congenital
disease.
f)There was no
congenital disease in the family
history.
2.
a)According to his statement, no other
members of his family have ever had (contracted)
the same
disease.
b)From his statement, there was no
similar disease in the other member of his
family.
c)He stated (said,
related, claimed, alleged, affirmed) that no other
members of his family were
similarly
affected.
3.
a)The family history was
noncontributory (unavailable).
b)F.H. was not remarkable
(contributory).
c)F.H.
revealed nothing remarkable (particular,
significant, worth recording)
d)No particular data were available
about the family history.
e)There was no relevant family
history.
f)F.H.:Nothing
relevant was indicated.
4.
a)He has a bleeding
tendency.
b)He has a
tendency to bleed.
c)He is
inclined to bleed.
5.
a)F.H. revealed that
hemophilia is transmitted (inherited) on the
maternal side.
b)Judging
from the family history, hemophilia ran in the
maternal line.
c)In the
family history there was a hemophiliac tendency on
the maternal side.
6.
a)He was born in a healthy
family without any evidence of hereditary
psychosis.
b)He was
(descended) from a family, healthy and free from
hereditary psychosis.
c)He
came from a healthy family without the slightest
trace of hereditary
psychosis.
7.
a)The cause of his father's
death is unknown (uncertain,
undetermined).
b)His father
died from an unknown cause.
c)His father died without definite
cause.
8.
a)He died at the age of twenty-eight of
pulmonary tuberculosis.
b)TB
caused (brought about) his death at 28.
c)He died of TB in his 28th
year.
9.
a)He died 5 days after he became
sick.
b)Five days after the
onset of his illness he died.
c)After an illness of 5 days he
died.
10.
a)He died at 1:25 a.m.
b)He was found dead in bed at 1:25
a.m.
c)His respirations
ceased at 1:25 a.m.
七、陳訴
Complaint
（
1
）陳訴的寫法
ex1<
/p>
：因為以前患過結核病，他有時訴說咳嗽、胸部不舒服和疲勞。
Having suffered from tuberculosis in
the past, he complained occasionally
of coughing, chest discomfort, and
prostration.
ex2
：
她在
1961
年住院，訴說最近發生中胸部痛、呼吸短促和心悸
。
In
1961
she
was
admitted
to
the
hospital
complaining
of
(with
complaint
of
；
because
of
)
mid-chest
pain of recent onset, breathlessness and
palpitations.
（
2<
/p>
）
~
感
-
恐懼
(
眩暈、噁心
、寒顫
)
感
a sensation of fear (giddiness, nausea,
chill)
-
異物
(
壓迫、窒息、燒灼、寒顫
)
感
foreign body (oppressive,
strangling,
burning, chilly)
sensation (feeling)
-
喉頭的癢感
itching sensation in one's
larynx
-
糢糊不舒服的感覺
vague ill feeling
-
咽喉上的束緊感
a feeling of constriction in one's
throat
-
在咽喉右邊的微癢感
a tickling feeling in the right side of
the throat
-
在
~
後頭部的特殊、難堪的感覺
a peculiar, weighty feeling in the back
of one's head
-
在右上腹部深處的糢糊不舒適感
a
vague
sense
of
unease
deep
in
the
right
upper
abdominal
quadrant
ex1
：她近來感覺，似有東西壓在膀胱上。
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
）主訴：應儘可能引用病人的話，說出現症的主要症狀，經過期間和找
醫師看病的原因。記述需扼要簡明並避免含糊語句，常用可用
簡寫的方式。
ex1
：從昨晚飯後，病人一直感覺寒戰。
Patient
has had chills after dinner since last
evening.
↓
可簡寫為
Chills since last
evening.
ex2
：主訴：胃
腫脹已
4
個月。
C.C.
：
“
Swelling
of the stomach
“
for 4
months.
ex3
：
2,3
個月來，一做工就感覺呼吸困難和眩暈。
For 2 or 3 months, dyspnea and
dizziness on work.
< br>（
4
）病歷的申述
-
不完全可靠
be not entirely reliable
-
不甚明晰
be not clearly defined
-
有些糢糊
be somewhat vague
-
無法獲得
be unobtainable
-
不能申述適當的病歷
can give no adequate history
-
混亂不很肯定
be uncertain and confused
ex1
：關於既往症，他不能提供可靠的報告。
He could not give reliable
information concerning former illness.
ex2
：因為他有精神激動，無法獲得可靠的病歷。
Because of his mental agitation,
no reliable history could be obtained.
（
5
）因<
/p>
~
病而轉入
~
科
治療
ex1
：她因為在皮膚科住院治
療未見轉好，而被介紹過來。
She
was
referred
because
there
had
been
no
relief
with
dermatologic
treatment,
including
hospitalization.
ex2
：
此病人現年
27
歲，
是剛離婚的經產婦，
經一所地方醫院診斷
為陰道腫瘤而轉入本院。
The patient was a 27-year-old recently
divorced multipara referred from a district
hospital with a
diagnosis of a vaginal
tumor.
（
< br>6
）全身狀態
-
精力缺失
lack of energy
-
只訴說全身無力
complain only a slight generalized
weakness
-
覺得遍身無力
feel week all over
-
不可言狀的眩暈
nondescript dizziness
-
胸骨下方的不舒服灼感
substernal burning
discomfort
-
飯後腹上部窘迫感
postprandial epigastric
distress
-
心臟部疼痛
precordial pain
-
胸內苦悶或重壓感
precordial
oppression
；
pressure on the
chest
；
tightness in the
chest
-
全年性的過敏性鼻炎
perennial allergic rhinitis
-
季節性的支氣管性喘息
seasonal bronchial asthma
-
一直不斷地說胃痛和頭痛
incessant complaints of stomach pains
and headaches
-
尤其
喝一杯牛奶後，有些不舒服的飽脹感
some
uncomfortable
full
feeling
especially
after
drinking one glass of
milk
-
偶而一時喪失意識
have occasional blackouts
-
肩僵硬
stiff shoulder
-
覺氣悶，覺氣息不舒
feel stifling (suffocating)
-
感覺疲乏
become tired ( fatigued,
weary)
；
have a tired
feeling
；
feel
languid
-
覺全身寒慄
feel a cold shuddering pass all
through~
-
覺得渾身發冷
fell a chill creep over~
-
頭暈目眩
one's eyes swim in one's
head
-(~
的
< br>)
腳麻木
have a
charlie horse (in one's leg)
ex1
：他差不多不斷地訴說飯後嘔吐。
He complained almost ceaselessly of
postprandial nausea.
ex2
：全身虛弱，而腿痛變得很厲害。
There
was general debility, and pain in the legs become
excruciating.
exercise2
1.
從前他一天抽一包煙，現在抽得更多。
2.10
年來，他一直喝大量的酒。
3.
他曾戒過酒，但無法戒掉。
4.
他每在晚餐時，喝一點酒。
5.
他滴酒不沾唇。
6.
他一向操勞過度，以致患病。
<
/p>
7.
他一連工作
8
小時，也不會感覺疲倦。
8.
這嬰
兒是經過足月的懷孕後，正常生產的。
9.
< br>他因身體欠佳，一直到
40
歲才結婚。
< br>
10.
她已結婚
5
年，仍未生育。
11.
他早睡遲起。
1.
a)He used to smoke a package of
cigarettes a day, and now he smokes more than
that.
b)In the past he
smoked a pack of cigarettes every day and now it
is on the increase.
c)Formerly he smoked daily a pack of
cigarettes but now a little more than
that.
2.
a)He has a history of excessive
alcoholic intake during the past 10
years.
b)He has drunk hard (
to excess; immoderately) for 10 years.
c)He has been a heavy( hard; great)
drinker since 10 years ago.
3.
a)In spite of
everything( Though he had tried) to stop drinking,
he did not succeed.
b)He had
abstained from drinking, but he still found it
hard to rid himself of the habit.
c)He had given up drinking once, but
without a complete success.
4.
a)He drinks a
little at supper time.
b)He
always takes small evening drink(
cups).
c)He drinks some wine
at supper.
5.
a)He does not drink at all.
b)He does not touch glass.
c)He is a teetotaler( total
abstainer).
6.
a)He used to overwork and this caused
his illness.
b)As a result
of constant overwork in the past he became
ill.
c)His sickness was
induced by constant overwork.
7.
a)He could
work 8 hours running without getting
tired.
b)He did not get
tired working 8 hours straight.
c)He could work 8 hours at a stretch
without fatigue.
d)He could
work for eight consecutive hours without feeling
tired.
8.
a)This infant, having been at full
term, was born without any difficulty.
b)This infant was given a normal birth
after full gestation.
c)This
infant was born at full term with normal
delivery.
9.
a)He did not get married until forty
because of his poor health.
b)Because of physical weakness he
remained unmarried until 40.
c)Physical weakness prevented him from
getting married until 40.
10.
a)She has
been married for 5 years, but she still remains
sterile.
b)She has been
married for 5 years, but has never been
pregnant.
c)She has no child
after 5 years of marriage.
11.
a)He goes to
bed early but rises late.
b)He has a habit of going to bed early
and getting up late.
c)He is
used to going to bed early and rising late.
八、發燒
Fever
（
1
）
3
天
來，口腔溫度從攝氏
37
度
6
分，一直升到攝氏
40
度。
The temperature has risen steadily
from 37.6°
C to 40°
C orally
over the past 3 days.
※發燒
-
發燒
become feverish; have a
temperature
-
發高燒
have a high fever
-
平常有微熱，有幾次升到
38.4
度
have low-grade (slight)
fever to 38.4
°
C on a few
occasions
-
沒有發燒
be afebrile; have no fever
<
/p>
ex1:
在發燒期間，他的平均體溫是攝氏
39
度。
He ran a
febrile course with an average temperature of
39°
C.
ex2:
他在患病期間尿量減少，並且發燒。
He was
obliguric and feverish (febrile) throughout the
course.
※體溫升高
-
體溫上升
have an elevation of
temperature
-
發高燒伴隨惡寒
have high temp. associated with
chill
-
體溫升升，有惡寒
have chills with high
temperature
ex1:
體溫升到攝氏
39
度
2
，腹部也明顯地膨脹了起來。
The temp.
rose( went up ) to 39.2°
C and the
abdominal distension became marked.
ex2:
最近
8
天的
口腔溫度升到
37.8
°
C
，但後來一直在
37.2
°
C
以下。
The
oral
temp.
was
elevated
to
37.8°
C
during
the
past
8
days,
but
thereafter
remained
below
37.2°
C.
（
2
）大約
在
4
月底，他的體溫，自然地降到攝氏
37
度。
About the
end of April, his temperature dropped to
37°
C spontaneously.
※體溫降低
-
體溫急速下降
one's fever falls (abates; declines)
promptly
-
體溫開始減低
fever began to remit
-
體溫似乎是減退了
fever seemed to abate
-
體溫降到正常
fever dropped (was reduced) to
normal
-
體溫慢慢地下降
(
上升
) with slow
lysis ( cirsis) of fever
-
體溫一天一天地低下來
fever became lower day by
day