英文病歷書寫用語及

常見錯誤
台中榮民總醫院內科部
過敏免疫風濕科
陳怡行醫師 蔡肇基醫師

英文書寫病歷的語言障礙
„ 雖然我國非英語系國家，但國內醫學教
育都是教導以英文來書寫病歷
„ 以中文或本土語言詢問病史後，再轉譯
為英文，除了症狀有時不易表達外，某
些較特殊的醫學敘述對於初學書寫病歷
的學生或醫師，也常造成辭不達意。

摘自 范碧玉 許清曉 黃勝雄 病歷書寫參考指引

1
 英文書寫病歷的語言障礙
„ 病人講台語,醫師講國語,病歷寫英文!
„ 因為語言的障礙, 病歷書寫便有很大的問
題
„ 簡化病人的敘述
„ 英文時態混亂
„ 英文文法錯誤

實況一
„ 先生阿！我的腹度teh 痛！
„ 醫生就問：「是頂腹或是下腹？是吃飽痛或是飢痛？
是cho-cho-a thia (遭遭痛)或是iū-iū a thia (悠悠痛)？」
„ 病人講：「是我的頂腹，是飽痛，不是飢痛。普通時
bun-bun a thia ( 悶悶痛)，但有時oe kiu kah thia (抽絞
痛)，有時thia ka laû chhin kōa (流淒汗)，也tuan-ki
keng-kah thâu(肩甲頭) 」
„ 醫生問：「Oe ek chhiah-Sng bò (會 溢 赤 酸 嗎)？」
„ 病人講：「Boe (不會)，但是Oe(會) khò u-ah (打嗝)，
Boe Phah-eh」

摘自黃勝雄醫師2003講稿

2
 英文病歷該怎麼寫???!

醫學台語的英文翻譯
„ Kho U-ah是英語的hiccup
„ Phah-eh是英語的belching
„ chīu 是英語的itching
„ pak-to tiu – tiu英語是feeling abdominal
distention
„ phah-ka-chhiu 英語是sneezing
„ tâu-khak gông-gông 英語是dull headache
„ sim-guah-thâu pok-pok chheng 英語是
palpitation
摘自黃勝雄醫師2003講稿

3
 實 況 二
„ 一個實習醫師在醫院，很仔細地看完病
歷後，診斷患者有胰臟發炎，於是去病
床邊跟老太太說：「O-bá-sáng，你ê “姨
丈”發炎！」。 老太太不解的說：「阮
阿母是孤子neh，我 to 無阿姨，beh安怎
有姨丈！」

摘自 鄭詩宗醫師2003講稿

病歷的英文時態
„ 時態 大多數的情形是以診察患者，而記載於
病歷表的現在為基準
„ 發病時的記述: 過去式
„ 發病前之狀態: 過去完成式
„ 發病以後至現在的經過: 現在完成式
„ 現在述說的症狀: 現在式

4
 病歷的英文時態
„ 過去式表示住院與門診時的情形（The
patient was admitted ）
„ 在這情況下，住院前的經過，則用過去完成式與過
去式記述之。
„ 用意味「經驗」的現在完成式亦可。
„ 在既往歷中，原則上都用過去式
„ 對於習慣的記載，則現在式
„ 對於家屬歷，用過去式及現在式
„ 對於系統別的病歷，則用與現病歷相同的時態

時態 (tense) 常見的錯誤
„ He had hypertension and still on three
kinds of antihypertensive.
„ 建議 :
„ 1.He has hypertension and still on three
kinds of antihypertensive.
„ 2. He has hypertension and is on three kinds
of antihypertensive.
„ 3. He has hypertension and is on three kinds
of antihypertensive medication.

5
時態 (tense) 常見的錯誤
„ Before he came to our clinic today, he
had ever went to another two hospital
clinics.
„ 建議 :
„ Before he came to our clinic today, the
patient had visited clinics at two other
hospitals.
„ Before he came to our clinic today, the
patient had been to clinics at two other
hospitals.

時態 (tense) 的錯誤
„ Before he came to our clinic today, he
had ever went to another two hospital
clinics.
„ 建議 :
„ Before he came to our clinic today, the
patient had visited clinics at two other
hospitals.
„ Before he came to our clinic today, the
patient had been to clinics at two other
hospitals.

6
 現在病況常用語句

病人或家屬描述基本用語

„ 陳述 tell, state, claim, assert,

describe
„ 認為 think, feel, believe, suspect
„ 根據、聲稱 according to-
„ 根據所憶 to the best of one’s memory,
as one,s recall
„ 就其所知 to one’s knowledge,
as far as one knows

7
 例句
„ The patient stated（claimed, said）that
he had abdominal pain just after meals.
„ The patient suspected (thought)that he
acquired his infection during a journey to
the Orchid island one week ago.
„ According to the patient’s family, he was
noted disoriented in time about half a
month ago.
„ The stool was believed tarry.

病人發現症狀或發病，或做檢查發現
基本用語
„ 症狀開始
„ Start, begin, appear, occur, develop
„ 表現出
„ manifest
„ 注意、發現
„ note, notice, find, aware of, feel, complain of
„ 遭受
„ suffer, seize, experience
„ (檢查）發現
„ reveal, show, detect

8
 例句
„ The patient began to have diarrhea three days ago.
„ Diarrhea started (developed)three days ago.
„ Brownish pigmentation appeared over the lower
limbs.
„ Initially the patient had poor appetite and nausea,
and jaundice became manifested three days later.
„ An enlarged spleen was noted (found) during routine
physical examination at school.
„ The patient was noticed to have elevations of serum
creatinine and uric acid at the annual medical
checkup.
„ The patient experienced a gradual onset of pain
around the lower back.
„ A chest x-ray examination revealed (showed) an
abnormal infiltration in the tight upper lung.

病人就診、住院、出院、進行檢查或
處置等基本用語
„ 就醫、求診
„ call (get, send for) a doctor, seek,medical advice
consult (see,visit) a doctor
„ 入院
„ admission to a hospital, be hospitalized
(admitted), enter, present oneself
„ 出院
„ be discharged, discharge, leave a hospital
„ 回診、複診
„ revisit, return visit, follow-up visit
„ 進行檢查或處置
„ undergo a test, do, take

9
 例句
„ 1.The patient sought medical advice for the swelling
of his scrotum.
„ 2. He entered the hospital (was admitted, was
hospitalized) because of chest discomfort and
palpitation for one day.
„ 3.The patient presented himself to the Emergency
Department of the City Hospital complaining of chest
pain and dyspnea for one hour..
„ 4. After discharge, the patient was released to a
practitioner’s care from the general hospital.
„ 5. A blood test was done (taken), and the result
showed 50 mg/dL of blood sugar.
„ 6. The patient underwent an emergent endoscopy and
a gastric ulcer over the body was noted.

描述過去健康情形基本用語
„ 健康狀況
„ healthy, well, poor,ill
„ 活力
„ vigorous, energetic, healthy
„ 健壯
„ robust, strong, stout
„ 虛弱、生病
„ weak , sick, ill, be afflicted with, be indisposed with
„ 臥床
„ be ill in bed, be bedridden, be confined to bed

10
 例句
„ 1. The patient had been in good health (had been well)
until two weeks ago when she had severe chest pain,
which occurred suddenly after paroxysmal cough.
„ 2.The patient had been robust without illness until
2003 when he had the first angina.
„ 3.The patient had enjoyed an excellent health until
two years ago when he experienced occasional chest
pain.
„ 4. The patient has been bed-ridden (confined to bed)
with paraplegia since the traffic accident happened
to him one one year ago.
„ 5.The patient claimed that he was prone to illness,
but had never sought medical advice.

發病時間、發病狀況
基本用語
„ 入院前
„ before (prior to) admission (entry, this visit)
„ 來診前
„ hospitalization,dated back to day ago
„ 住院中
„ during admission (hospitalization, hospital stay)
„ 突然的
„ suddenly, abruptly, an abrupt (acute, sudden) onset
„ 徐徐的
„ slowly, gradually, insidiously, a gradual onset

11
 例句
„ 1.Severe headache and high blood pressure developed
two days before admission (prior to this entry,
hospitalization).
„ 2. During the three months before entry, the patient
experienced progressive loss of weight and appetite.
„ 3.The onset of abdominal pain can be dated back to one
week ago.
„ 4. The patient had symptoms of hyperthyroidism dating
to his late twenties.
„ 5.The patient experienced an abrupt onset of chest pain
and dyspnea.
„ 6. He had swelling of the lower legs gradually
(insidiously).

症狀描述部位 基本用語
„ 發生在部位
„ be located, be situated (in, at, over), be felt be present
„ 侷限於
„ be localized, be limited, be restricted, locally
„ 全身性的
„ general, generalized, systemic, the whole body over the
entire body
„ 蔓延至、放射至
„ spread, extend reach to, diffuse, radiate, migrate

12
 例句
„ 1. The burning sensation was located (felt) in
the left lower quadrant of the abdomen.
„ 2. The reddish skin was limited to the right
instep and did not extend above the ankle.
„ 3. The sharp pain started in the right flank and
radiated to the tight hypochondrium and even
down to the scrotum.
„ 4.The pain began in the right temporal area aide
spread more widely over that side of the head
when the severity of pain increased.

頻率、嚴重度 基本用語
„ 長期、慢性的
„ long-term, long-standing, chronic, prolonged
„ 短期、急性的、偶爾、發作幾次
„ short-term, brief, a short duration, acute occasionally, on one occasion,
an episode of
„ 持續的 時常的
„ continuously, constantly, persistent, frequently last
„ 一時的、間隔的
„ temporary, transient, fleeting, intermittent, off and on
„ 輕度
„ mild, slight, a touch of
„ 中度
„ moderate, proper
„ 重度
„ severe, intense, violent, marked

13
 例句
„ 1. Tarry stool persisted over the next five days.
„ 2. The blood-streak stool was noticed at least on two occasions.
„ 3.The headache has become frequent, occurring every five minutes
(at intervals of five minutes).
„ 4. For the past two weeks, the patient has had several paroxysms of
dyspnea, which usually occurred at night and lasted for about 15
minutes.
„ 5. Constipation and diarrhea came alternately.
„ 6. The epigastralagia gradually increased in severity.
„ 7. The chest pain, localized mostly over the left lateral chest,
decreased in severity or was minimal when breath was held, but was
aggravated by inspiration.
„ 8. The patient had a slight (touch of) cold.
„ 9. The patient remained gravely ill after cholecystectomy, although
his jaundice and liver function were not deteriorated.

症狀的量化及形容
基本用語
„ 量
„ a little, scanty, plenty of, a large (small)
amount gain (loss) weight, voluminous, bulky
„ 數、次數
„ a few, small in number, numerous, a
large number of, increase (decrease) in
number
„ 大小
„ be the size of, sized of, diminish (decrease
increase) in size (length, width)
„ 形狀、顏色
„ in shape, shaped, be tinted (tinged) with …

14
 例句
„ 1. The patient began to have change of his bowel habit
characterized by five to seven loose brown stools a
day.
„ 2. After a paroxysmal cough, the patient expectorated a
tablespoonful bloody sputum.
„ 3. A hen egg-sized lump has been noted on the abdominal
wall without change in size or shape for the past ten
years.
„ 4. The patient had intermittent cough for more than 20
years, and began to have a small amount of blood-
streaked (tinged) sputum in recernt three months.
„ 5. Pinhead-sized papules initially occurred over the upper
arms, increased rapidly in number and spread to the face
and trunk.

症狀的誘因基本用語
„ 誘發、引起、影響
„ trigger, cause, precipitate, induce,
bring about, incite, provoke, influence,
affect
„ 前因
„ precede, antecedent
„ 傾向
„ tend to, be apt to, have a tendency to

15
 例句
„ 1. The patient cannot recall any precipitating (provoking)
factor of the attack.
„ 2. The chest pain was inevitably provoked (caused, induced)
by walking for about 10 minutes and disappeared after
taking a rest.
„ 3. The cramping ache was present constantly in the lower
abdomen, unaffected (not influenced) by meals or bowel
movement.
„ 4. The patient recalled no preceding cold or tonsillitis before
the occurrence of hematuria.
„ 5. The patient had a tendency toward cold sweating and
dizziness before lunch, which could be relieved of by
taking a snack.
„ 6. She tended to fall forward or backward when she closed
her eyes.

伴隨或相關症狀
基本用語
„ 伴隨
„ with, along with, concurrently, coincide with, accompany,
simultaneously
„ 合併
„ be accompanied by, be complicated with (by), concur
„ 續發
„ following, be followed by, succeed, ensue
„ 相關、有關連
„ be related to, be associated with,
„ have nothing to do with

16
 例句
„ 1. Concurrently, the patient had abdominal pain
and diarrhea, in addition to vomiting
„ 2. Pedal swelling persisted and was unrelated to
postures.
„ 3. The chest pain was closely related to
(associated with) position, movement, and
swallowing.
„ 4. The cough was followed by dyspnea and a
fainting attack few minutes later.
„ 5. The fracture of the left femur was
complicated with pulmonary embolism.(The
pulmonary embolism was preceded by a sever
fracture of the left femur.)

姿勢或活動的相關症狀基本用語
„ 運動 on exertion, on exercise
„ 排尿 on urination, when voiding
„ 仰臥、平躺 a recumbent position, a lying posture, in s
supine position
„ 俯臥 in prone position, pronely, in a ventral decubitus
„ 側臥 on one’s (right or left) decubitus
„ 蹲 on squatting
„ 彎腰 in a leaning (stooping, redlining, stooping) position
„ 爬樓梯 climbing stairs, ascend 3 flights of stairs
„ 受限制 limit, restrict, confine
„ 有困難 trouble, difficult
„ 受干擾 prevent, disturb, interrupt
„ 困擾於 annoy, bother, trouble

17
 例句
„ 1. The patient often felt dizzy when rose suddenly from recumbent
or sitting position.
„ 2. The backache was mild on standing erect, and could be partially
relieved by bending forward.
„ 3. The pain could be significantly decreased by lying on his right
decubitus.
„ 4. Last night the patient sat up in bed the night, because he was
unable to breathe on his back.
„ 5. The patient has to squat after walking for several minutes.
„ 6. The weakness made the patient difficult in standing up after
kneeling for her prayer.
„ 7. The knee pain limited his daily jogging.
„ 8. Troubled (annoyed) with the unexpected fits following the
accident, the patient had to quit his job.
„ 9. The frequent urge to ruinate interrupted (disturbed) the
patient’s sleep.

病情變化基本用語
„ 病情變好、緩解、減輕
„ Progressing favorable, doing well, make a
favorable progress relief, remission, palliation,
lessen, diminsih
„ 病情轉壞、惡化
„ take an unfavorable course, make an
unsatisfactory progress, getting worse,
aggravated, worsen, an unfavorable progress
„ 復發
„ recurrence, relapse, flare-up, recrudescence
„ 接受治療
„ receive (take) treatment, be under treatment,
drugs be presxribed

18
 例句
„ 1. After the operation, the patient made a favorable
progress.
„ 2. The pain of the ankle was relieved promptly after the
patient took the doctor’s prescription.
„ 3. In spite of intensive management of his heart failure,
the patient’s consciousness got worse and was
aggravated by pneumonia.
„ 4. The leg edema subsided gradually after the patient
took Prednisolone. But, recurrence was noted tow weeks
after his discontinuation of medicine.
„ 5. The activity of systemic lupus erythematosus flared-
up after three years’ quiescence.

以英文記載病例
常見錯誤

19
 中榮實例ㄧPresent Illness
„ This 38 y/o man had histories of 1. SLE diagnosed at VGHTP on 1999 with
initial presentation of intermittent fever, foamy urine, skin rash over whole
body and malar rash. 2. Herpes zoster extended from right chest to back
occurred before SLE. 3. bil renal stone s/p ESWL about 2 yrs ago.

„ He had ever admitted to our hospital in this May due to pleural pain but
only minimal pleural effusion noted. There was also mild pulmonary fibrosis
noted ar that time. His symptoms improved after increased prednisolone
dosage. He was discharged and then regular follow-up for his SLE at 新光
Hospital with regular medications. This Aug. he had ever received Endoxan
therapy due to pregressed of proteinuria at 新光 H. But hydorcele and
intermittent fever develop since he discharged. This Nov. he received
orchiectomy and found there was pus formation of his testise. Culture yield
TB and then he started to take anti-TB drugs with Rifater and EMB.

„ He visited our IMRH OPD due to RUQ pain on 11/07. He stated that the
pain was intermittent since this May and incresed frequency in recent 1
month(2 times/week to persistent). The pain was exacerbated when he
deep breathing or sneezing. It was dull pain but sometimes it became
tingling pain. There was no fever, no chillness, no URI symptoms, no
appetite or bowel habit change noted. There was also no renal colic or
Murphy sign noted. Sonogram on 11/01 showed only mild hydronephrosis.
This time he was admitted for further survey of his RUQ pain.

中榮實例二 會診單

DEAR DOCTOR:
THE 68Y/O MALE WAS A VICTIM OF
CERVICAL CA S/P R/T WITH RADIATI
ON CYSTIS.SHE HAD RHEUMATOID ART
HRITIS HISTORY FOR YEARS.
WE SINCERLY NEED YOUR EEXPERTISE
TO EVALUATE HER CONDITION AND
SU GGEST MEDICATION USE.
THANKS ALOT!

20
 介係詞的錯誤
„ Inlast Saturday, his headache was
suddenly got worse.
„ 建議 :Last Saturday, his headache suddenly
got worse.
„ Thepatient had an acute process
superimposed to his background
conditions.
„ 建議 :The patient had an acute process
superimposed on his background conditions.

主詞的錯誤

„ Cancer was told.

建議 :
„ The patient was informed to have cancer.
„ Patient was told to be having cancer.
„ He was diagnosed to have cancer.
„ He was told to be having cancer,

21
 單字、單辭的錯誤
„ Discharge diagnosis: R/O cancer.
„ 建議:R/O（rule out）是‘須排除’ 、‘應排除’
之意，R/O cancer可用於住院時的診斷。
不過住院診斷工作（work up）之後，癌症
的診斷應該是已經被rule in 或rule out。如
診斷仍未被確認，而癌症還是最有可能，則
應寫成Discharge diagnosis: probable
cancer 或 suspected cancer 。

錯誤使用normal 或negative
„ Physicalexamination was normal. (or
negative）
„ 建議
„ Physical examination revealed no
abnormalities.
„ Results of physical examination were
normal.
„ No abnormalities were disclosed (found,
noted, detected) on physical examination.

22
 錯誤使用normal 或negative
„ Laboratory was negative.
„ The biopsy was negative.
„ The ECG was negative.
建議
„ Laboratory test (studies) gave normal results.
„ Laboratory tests showed normal values.
„ Laboratory data were normal (or within normal
limits).
„ The result of the biopsy was unremarkable.
„ The (renal, lung) pathology of the biopsy did not
reveal abnormal findings.
„ The ECG revealed no abnormality.

Nothing particular (N.P)

或 non-made的誤用
„ The family history was nothing particular.
„ 應改為 : The family history was unremarkable (or
non-contributory).
„ The biopsy was non-made.
„ The pathology was non-made.
„ 應改為 : The pathology did not reveal malignant cells.
„ No malignant cells were found in the biopsy
specimen.

23
 贅語或俗語
„ Seizure attack
„ 只需寫seizure，或epileptic fit。
„ A tumor mass
„ 應寫為a tumor, a mass (lesion) 。
„ Fever if 38℃
„ 應寫為(fever with) a temperature of 38℃。
„ The patient was AAD (against advice discharge，自
動出院) ，
„ 應寫為The patient was discharged AMA (against medical
advice)或 to be discharged AMA或discharge AMA。
„ The patient MBD (may be discharged) today.
„ 應寫為 The patient is ready for discharge today.
„ to be discharged
„ discharge today
„ discharge tomorrow morning
„ discharge in AM 或 to be discharged today。

其他常見的不當使用語詞
„ Victim
„ Victim翻譯是‘受害者’ ，通常指犯罪謀殺案或車禍意外之
受害者
„ The patient is victim of type 1 DM
diagnosed since 2 years ago.
„ 應寫為 : The patient was diagnosed as having
type 1 DM two years ago.
„ The patient is a victim of motor vehicle
accident (MVA).
„ 應寫為 : The patient is a victim of motor vehicle
accident (MVA).
„ 也可寫成The patient had an MVA.

24
 其他常見的不當使用語詞
„ Unfortunately
„ 常見病歷書寫‘Unfortunately, the patient
had…’ ，這個意思是說病人的情況本來是穩定的，
但是後來發生了某些症狀或事件。病人生病本來
就事不幸的事，不須再強調，不須加哀傷的語氣
如unfortunately、sadly、miserably、unluckily
等呈現在病歷。
„ Unfortunately,nausea, vomiting and
abdominal pain developed since last night,
and the patient was brought to ER for
help.

其他常見的不當使用語詞
„ CT scan of the head was arranged
(performed), which showed subdural
hematoma over the left parietal area.
„ 應寫為 :A CT scan of the head showed
subdural hematoma over the left parietal
area.

25
 其他常見的不當使用語詞
„ Culture showed bacteria
„ 細菌培養長出細菌不適用show或reveal，
應該用yield或grow。
„ The sputum culture showed
Streptococcus pneumonia infection.
„ 應寫為 :The sputum culture yielded
(grew) Sreptococcus pneumoniae.
„ Bacteria culture was positive for
Streptococcus pneumoniae

其他常見的不當使用語詞
„ According to the statement of the
patient
„ 這似乎強調這份病歷是病人親口說的，其實病歷
不是司法的筆錄，只要說是根據病人的陳述即可，
或是直接說病人如何。
應改為 :
„ According to the patient.
„ 或 The patient stated that she had epigastric
discomfort 30 minutes after last dinner.
„ 或是 The patient had epigastric discomfort
30 minutes after last dinner.

26
 其他常見的不當使用語詞
„ During the period of admission
„ 這是中式英文的另一例子，亦即‘住院期間’ 。
但是admission是由醫院進入病房的一種行為，
因此沒有所謂period。
„ 應該寫為During the hospitalization
„ 或是 At hospital。

其他常見的不當使用語詞
„A disease was diagnosed.
„ The patient was diagnosed as a disease.
„ 中文的意思很簡單， ‘病人診斷什麼病’ ，但是
英文不能寫為‘疾病被診斷’ ；也不能寫為‘病人
被診對成(as a disease)什麼病’ 。
„ Colon
cancer was diagnosed.
„ 應寫成 :
„ The patient was diagnosed as having colon
cancer.或是 A diagnosis of colon cancer was
made.

27
 其他常見的不當使用語詞
„ 使用太多連接詞，使句子太長
„ The patient went to the hospital and was
diagnosed of osteoarthritis, so
medications were given and the pain
decreased in severity, but she had to tale
the medicines regularly.
„ 應寫成 :The patient went to the hospital,
where a diagnosis of osteoarthritis was made.
Medication were prescribed to relieve her
pain and sht tool them frequently.

其他常見的不當使用語詞
„ Irregular control, Regulat medication
„ 應寫為 :
„ The patient has had hypertension for 10 years, but
he did not take medicine as ordered.
„ The patient has been hypertension for 10 years, but
he has not been taking medicine as ordered.
„ The patient has had hypertension for 10 years, but
he has not been taking medicine as ordered.
„ The patient has been hypertensive for 10 year, but
his busy work kept him from taking medicines as
ordered.
„ 如果知道病人因不按時服藥，造成血壓控制不佳，也可
以寫為:The patient has had hypertension for 10
years, his blood pressure was poorly controlled
because he did not take medicine as ordered.

28
 其他常見的不當使用語詞

Ever
„ The patient ever went to a hospital.
„ 建議 :
„ The patient has been to a hospital.
„ The patient did go to a hospital.
„ The patient went to a hospital.

其他常見的不當使用語詞
Consious (consciousness)
„ The patient is anemia. Conscious clear.
„ 建議 :
„ The patient is anemic.或
„ The patient has anemia.
„ Consciousness: clear.或
„ Consciousness: alert, coherent, and
oriented as to place, person and time (常
寫成oriented ×3)。

29
 其他常見的不當使用語詞
„ In
vain
建議 :
„ The patient went to his primary care
physician for treatment, but the
symptoms did not improve.
„ 或the treatment was not effective。

其他常見的不當使用語詞

Impressed 指印象深刻
„ Cancer was impressed.
建議 :
„ Cancerwas suspected.
„ Impress在這種場合不能用作動詞。

30
 其他常見的不當使用語詞
Developed
„ The patient developed abdominal pain
and high fever.
建議 :
„ Abdominal pain and high fever developed.

其他常見的不當使用語詞
Consultation
„ Thank you for the consultation.
建議 :
„ Thank you for the referral.
„ Thank you for the consultation request.
„ 或簡單地Thanks！
„ 但不能寫 Thank you for the consultation.
（這樣寫變成感謝自己的意見了）

31
英文裡沒有的說法,中榮版
病例卻常見到的用詞
General weakness?
全身無力?!
„ Malaise
„ Fatigue
„ Muscle weakness
„ Asthenia

malaise

„A vague feeling of bodily discomfort

„
A feeling of general discomfort or
uneasiness, an out-of-sorts feeling,
often the first indication of an
infection or other disease.
http://www.cdc.gov/ncidod/diseases/cfs/glossary.htm

32
 fatigue

„ The state following a period of

mental or bodily activity,
charaterised by a lessened capacity
for work and reduced efficiency of
accomplishment, usually accompanied
by a feeling of weakness, sleepiness,
or irritability

muscle weakness
„A vague complaint of debility, fatigue,
or exhaustion attributable to
weakness of various muscles. The
weakness can be characterized as
subacute, or chornic, often
progressive, and is a manifestation of
many muscle and neuromuscular
diseases
(From Wyngaarden et al., Cecil Textbook of Medicine, 19th ed, p2251)

33
 Asthenia

„ Clinicalsign or symptom manifested

as debility, or lack or loss of
strength and energy

Lethargy
„ Abnormal drowsiness or stupor, a
condition of indifference

34
 中榮實例ㄧPresent Illness 修正版
„ This 38 y/o man has been diagnosed of having SLE in 1999 with initial
presentation of intermittent fever, foamy urine, skin rash over whole body
and malar rash.
„ He had been admitted to our hospital in May this year due to pleural pain
but only minimal pleural effusion was noted. There was also mild pulmonary
fibrosis at that time. His symptoms improved after increasing the dose of
prednisolone. He was discharged and then regularly follow-up for his SLE
at 新光 Hospital with medication as ordered. In August this year. he had
ever received Endoxan therapy due to progression of proteinuria at 新光 H.
But hydorcele and intermittent fever developed since he discharged. In
Nov. this year, he received orchiectomy and was found pus formation in his
testise. Culture yielded TB and then he started to take anti-TB drugs
including Rifater and EMB.

„ He visited our IMRH OPD due to worsening of RUQ pain on 11/07. He

stated that the pain was intermittent since this May and incresed
frequency in the recent 1 month(2 times/week to persistent). The pain
exacerbated when he makes adeep breath or sneezes. It is dull pain but
sometimes becomes tingling. There was no fever, no chillness, no URI
symptoms, no appetite or bowel habit change noted. There was also no renal
colic or Murphy sign noted. Sonogram on 11/01 showed only mild
hydronephrosis. This time he was admitted for further survey of his RUQ
pain.

中榮實例二 會診單 修正版

DEAR DOCTOR:
THE 68Y/O MALE WAS A VICTIM OF CERVICAL CA S/P
R/T WITH RADIATI ON CYSTITIS.SHE HAD
RHEUMATOID ARTHRITIS HISTORY FOR YEARS. WE
SINCERLY NEED YOUR EEXPERTISE TO EVALUATE HER
CONDITION AND SU GGEST MEDICATION USE.
THANKS ALOT!

This 68 year-old lady has cervical cancer and had received

radiotherapy before. She has been admitted to our section
because of hemorrhagic cystitis. She has had rheumatoid
arthritis for 13 years or more but she did not take medication
as order. As she has been complaining widespread pain since
admission, we need your expertise to evaluate and manage her
joint problem.

35