病历 case histroy 一般事项 date of admission /marital status /present address /correspondence / occupatio n 主诉 chief complaints 现病史 present illness / history of present illness 既往史 past medical history 家族史 family history 个人病史 personal history / social history 曾用药物 medications 过敏史 allergies 系统回顾 system review / review of system 体检 physical examination 一般资料 physical data ,这里有戴尔
图片存档系统方面的， 生理指标 physical signs 一般状况或全身状况 general appearance 头眼与耳鼻喉 head ,eyes,ear,nose,throat ,略作 heent. 胸部与心肺 CHEST,heart,and lungs 腹部 abodoms 四肢 extremities 神经系统 nervous system,Neurological,略作 CNC 或 Neuro, 骨骼肌系统 Musculoskeletal 泌尿生殖系统 Genitourinary 化验室资料 laboratory data/ studies /diagnosis 血液检查 blood test 化学 7 项指标 chem.-7 心脑电图 electrocardiogram / electroencephalogram , 略作 EKG/EEG X 线检查与 x 光片 X-ray examination, x-ray slides, 计算机 X 线断层扫描与核磁共振扫描资料 computerized x-ray tomography and nuclear mag netic resonance spectroscopy dta. CT AND NMR 其他检查资料 other lab data 印象与诊断 impression and diagnosis 住院治疗情况 hospital course 出院医嘱 discharge instructions / recommendations 出院后用药 discharge medications 2 看病时用英文 1) 一般病情: He feels headache, nausea and vomiting. (他觉得头痛、恶心和想吐。) He is under the weather. (他不舒服，生病了。) He began to feel unusually tired. (他感到反常的疲倦。) He feels light-headed. (他觉得头晕。) She has been shut-in for a few days. (她生病在家几天了。) Her head is pounding. (她头痛。) His symptoms include loss of appetite, weight loss, excessive fatigue, fever and chills. (他的症状包括没有食欲、体重减轻、非常疲倦、发烧和发冷。) He feels exhausted or fatigued most of the time. (他大部份时间都觉得非常疲倦。) He has been lacking in energy for some time. (他感到虚弱有段时间了。) { 枫下论坛 .net /forum } He feels drowsy, dizzy and nauseated. (他觉得昏昏欲睡，头晕目眩和想吐。) He feels as though everything around him is spinning. (他感到周围的东西都在打转。) He has noticed some loss of hearing. (他发觉听力差些。) She has some pains and itching around her eyes. (她眼睛四周又痛又痒。) (2) 伤风感冒： He has been coughing up rusty or greenish-yellow phlegm. (他咳嗽带有绿黄色的痰。) His eyes feel itchy and he has been sneezing. 建议你去找一下dell电子病历
[ 此帖被dellyy在2011-11-03 12:57重新编辑 ]
