英文病历常见句型
Common sentence patterns in English medical records
一般项目 （general data）
主诉 （chief complaint, C.C.）
现病史 （present history/ present illness, P.I.）
既往病史 （past history/past medical history, P.H.）
家族病史 （family history, F.H.)
个人史（personal history/social history, Per.H.)
曾用药物(medications)
过敏史 （allergies)
体格检查 （physical examination, P.E.)
实验检查和其他辅助检查 （laboratory and aided examination）
诊断 （diagnosis,Impression）
住院治疗情况记录 (hospital course)
出院医嘱 (discharge instructions, recommendations)
出院后用药 (discharge medications)
主诉chief complaint
The patient was admitted/ seen in the office with a chief complaint of … 病人入院主诉……
The patient complained chiefly of 病人主诉……
The patient presented/entered with/ came to the office with a chief complaint of 病人主诉……
The patient was admitted because of 病人因……入院
The patient was referred to…because… 病人因……转诊到……
现病史present history
…first noted/noticed/ perceived/ recognized the onset of … 首次发现……（疾病症状）
…had abrupt/sudden/explosive onset of… 突然发生……（疾病症状）
…be characterized by… ……（疾病）的特征是……
…without/with no/ free of …(symptoms) ……没有……症状
There be no history of …/have no history of … 没有……病史
…improve/take a favorable/ good turn （疾病）病情好转
…cease/clean up/disappear/subside 症状减退
…worsen/ be aggravated/ intensified/ alleviated 症状加重
Remain the same as…/continue…/persist without change 病情和之前一样/无变化
Be preceded by… 之前（有）……
Be followed by… 之后（有）……
Be accompanied by…/coincide with…/be associated with… 伴有…… 既往病史
…had been sound/well/ healthy/normal until…(disease) 患者在（患…病）前身体非常健康
Past medical history included… 既往病史包括……
…denied any history of …/…had no related history of …/…denied experiencing/ having attack of …
病人否认患过……/无……相关病史/没患过……
…was inoculated against… ……接种过预防……的疫苗个人史
…work/act/serve as…, …engage in… 以…为业
…married for …years with/without…… …结婚…年，有/无 （孩子）
…have had…pregnancies, with a history of…(abortion/premature birth) ……怀孕……次，有（流产/早产史）
家族史family history
No family history of … 无……家族史
Family history showed/revealed… 家族史显示……
There was a high prevalence of… in the family. 家族中患……病几率高