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    英语医学病历书写手册第三章:现病史

       作者:古龙   2009-07-04
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            现病史书写的重点包括:
           一、主诉中症状的详细描述;
           二、疾病的发展过程;
           三、诊疗经过;
           四、目前的一般情况。
           1、诱因
           •无诱因下[With no inducing factors]
           •无明显诱因下[Under no obvious predisposing causes]
           •感冒一周后[After getting (catching) common cold for 1 week]
           2、症状出现的叙述
           •有……症状
               ▲suffer from
           ▲ have an attack of
           ▲ have(fell)
           ▲ begin to fell
           ▲ a feeling (sensation) of……
           ▲ complain (of)
           ▲ ……sensation (feeling) in (of) ……
           ▲ [发热]have a temperature (become feverish)
           •在……情况下发生
           ▲ 活动时呼吸困难[dyspnea on exertion]
           ▲ 躺下后即出现咳嗽[Cough occurs soon after lying]
           •与……有(无)关
           ▲ 与……有关[be associated with]
           ▲ 与……有关[have (make) relation to]
           ▲ 与……无关[have (make)no relation to]
           •在……情况下加重(减轻)
           ▲ 餐后加重[become worse after taking meals]
           ▲ 站立后缓解[be relieved by standing up]
           ▲ 随呼吸和咳嗽而加重[become more severe with breathing and cough]
           •伴有……
           ▲ be accompanied by

    3、起病方式
           •急性腹痛[acute abdominal pain]
           •慢性低热[chronic lower fever]
           •暴发性发病[the onset was fulminating]
           •骤起胸痛[an explosive onset of chest pain]
           •突然起病伴高热[the onset was sudden with high fever]
           •突发突止[attacks began and ended abruptly]
           •因……而突然起病[the attack is precipitated by……]
           •很快发生晕厥[syncope occured rapidly]
           •逐渐出现咳嗽咳痰[gradual onset of cough and sputum]
           •偶而[occasionally (sporadically, accidentally)]
           •反复胸闷心悸[recurrent (bouts of) chest discomfort and palpitation]
           •一过性发作[transitory attack]医.学.全.在线.网.站.提供
           •连续胸痛[chest pain continually]
           •时重时轻[waned and waxed]
           •时好时坏[hang in the balance]
           •不停地咳嗽[have a fit of cough]
           •发作性呼吸困难[paroxysmal short of breath]
           •频繁咳嗽[cough frequently (very often)]
           •持续性(间歇性)[persistent (intermittent)]
           •频发胸痛[frequent episodes of chest pain]
           •持续不变[be steady]
           4、病情变化描述
           •[症状好转]  ▲fell better than before
                 ▲take a favorable turn
                 ▲take a turn for the better
                 ▲improve
                 ▲make favorable progress
                 ▲turn for the better
                 ▲change for the better
                 ▲be better
           •[症状减轻]  ▲alleviate
               ▲reduce
               ▲palliate
               ▲diminish
               ▲ease(lighten)
               ▲mitigate
           •[症状消失]  ▲disappear
               ▲subside
               ▲regress
               ▲clear up
               ▲vanish
               ▲dissolve
               ▲die (fade) away
               ▲relieve
           •[症状加重]  ▲be (make,become,get) worse
               ▲worsen
               ▲become more severe
               ▲take a turn for the worse
               ▲be aggravated
               ▲increase in severity
               ▲take a bad turn
               ▲make (become) more serious
               ▲make (become) heavier
           •[无变化]  ▲remain the same as……
               ▲continue without change
               ▲be identical
               ▲be alike
               ▲be similar
               ▲resemble
           •[时好时坏] ▲wane and wax
               ▲hang in the balance
           •[体温/血压升降]
           ▲ 升至[rise (go up) to ]
           ▲ 已升至[have risen (gone up) to ]
           ▲ 从……升至……[go up from …… to……]
           ▲ 升至[be elevated to]
           ▲ 迅速下降[fall (decline, abate) abruptly]
           ▲ 骤降(升)[sudden drop (elevation)]
           ▲ 渐降(升)[fall (elevate) gradually]
           ▲ 缓慢下降[slow crisis (lysis) of ]
           ▲ 一天天下降[be (become) lower day by day]
           ▲ 开始降低[begin to remit]
           ▲ 降至正常[drop (was reduced) to normal]
           ▲ 已降至[have gone down (dropped) to]
           ▲ 回复到正常[return (revert) to normal]
           ▲ 由……降(升)至……[fall (elevate) from……to……]
           ▲ 维持在……水平[maintain at a level of……]
           ▲ 稳定在……[stabilize at……]
           ▲ 热退了[fever disappeared]
           ▲ 不超过[do not go up over (exceed)……]
           ▲ 在……和……之间波动[fluctuate (vary) between……
           and……]
           ▲ 在……至……范围内[range from……to……]
           ▲ 平均38.5℃[an average temperature of 38.5℃]
           ▲ 有39.2℃的体温[have fever (a temperature) of 39.2℃]
           5、症状的时间表示
           •持续  ▲lasted for 2 days
              ▲have gone on for 1 month
              ▲have continued for 10 hours
              ▲lasted on the average 3-5 hours
              ▲lasted a variable time from 5 minutes to several hours
              ▲lasted about half an hour
           •超过(不到)[move than (less than)]
           •……以前[two years ago]
           •多在……时发生[usually between 3 and 5 PM]
           •未发作过[be free of onsets (attacks) for 2 weeks]
           6、症状的严重程度
           •轻度[mild (slight)]
           •中度[moderate]
           •重度[severe (serious)]
           来源:医学全在线

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