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您現(xiàn)在的位置: 醫(yī)學(xué)全在線 > 醫(yī)學(xué)英語(yǔ) > 英語(yǔ)教學(xué) > 英文病歷 > 正文:簡(jiǎn)明病歷書(shū)寫手冊(cè)第三章:現(xiàn)病史[History of present illness (HPI/PI)]
    

英語(yǔ)醫(yī)學(xué)病歷書(shū)寫手冊(cè)第三章:現(xiàn)病史[History of present illness (HPI/PI)]

現(xiàn)病史書(shū)寫的重點(diǎn)包括:
    一、主訴中癥狀的詳細(xì)描述;
二、疾病的發(fā)展過(guò)程;
三、診療經(jīng)過(guò);
四、目前的一般情況。
1、誘因
•無(wú)誘因下[With no inducing factors]
•無(wú)明顯誘因下[Under no obvious predisposing causes]
感冒一周后[After getting (catching) common cold for 1 week]
2、癥狀出現(xiàn)的敘述
•有……癥狀
    ▲suffer from
▲ have an attack of
▲ have(fell)
▲ begin to fell
▲ a feeling (sensation) of……
▲ complain (of)
▲ ……sensation (feeling) in (of) ……
▲ [發(fā)熱]have a temperature (become feverish)
•在……情況下發(fā)生
▲ 活動(dòng)時(shí)呼吸困難[dyspnea on exertion]
▲ 躺下后即出現(xiàn)咳嗽[Cough occurs soon after lying]
•與……有(無(wú))關(guān)
▲ 與……有關(guān)[be associated with]
▲ 與……有關(guān)[have (make) relation to]
▲ 與……無(wú)關(guān)[have (make)no relation to]
•在……情況下加重(減輕)
▲ 餐后加重[become worse after taking meals]
▲ 站立后緩解[be relieved by standing up]
▲ 隨呼吸和咳嗽而加重[become more severe with breathing and cough]
•伴有……
▲ be accompanied by

3、起病方式
•急性腹痛[acute abdominal pain]
•慢性低熱[chronic lower fever]
•暴發(fā)性發(fā)病[the onset was fulminating]
•驟起胸痛[an explosive onset of chest pain]
•突然起病伴高熱[the onset was sudden with high fever]
•突發(fā)突止[attacks began and ended abruptly]
•因……而突然起病[the attack is precipitated by……]
•很快發(fā)生暈厥[syncope occured rapidly]
•逐漸出現(xiàn)咳嗽咳痰[gradual onset of cough and sputum]
•偶而[occasionally (sporadically, accidentally)]
•反復(fù)胸悶心悸[recurrent (bouts of) chest discomfort and palpitation]
•一過(guò)性發(fā)作[transitory attack]醫(yī).學(xué).全.在線.網(wǎng).站.提供
•連續(xù)胸痛[chest pain continually]
•時(shí)重時(shí)輕[waned and waxed]
•時(shí)好時(shí)壞[hang in the balance]
•不停地咳嗽[have a fit of cough]
•發(fā)作性呼吸困難[paroxysmal short of breath]
•頻繁咳嗽[cough frequently (very often)]
•持續(xù)性(間歇性)[persistent (intermittent)]
•頻發(fā)胸痛[frequent episodes of chest pain]
•持續(xù)不變[be steady]
4、病情變化描述
•[癥狀好轉(zhuǎn)]  ▲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
•[癥狀減輕]  ▲alleviate
    ▲reduce
    ▲palliate
    ▲diminish
    ▲ease(lighten)
    ▲mitigate
•[癥狀消失]  ▲disappear
    ▲subside
    ▲regress
    ▲clear up
    ▲vanish
    ▲dissolve
    ▲die (fade) away
    ▲relieve醫(yī)學(xué).全.在線.網(wǎng).站.提供
•[癥狀加重]  ▲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
•[無(wú)變化]  ▲remain the same as……
    ▲continue without change
    ▲be identical
    ▲be alike
    ▲be similar
    ▲resemble
•[時(shí)好時(shí)壞] ▲wane and wax
    ▲hang in the balance
•[體溫/血壓升降]
▲ 升至[rise (go up) to ]
▲ 已升至[have risen (gone up) to ]
▲ 從……升至……[go up from …… to……]
▲ 升至[be elevated to]
▲ 迅速下降[fall (decline, abate) abruptly]
▲ 驟降(升)[sudden drop (elevation)]
▲ 漸降(升)[fall (elevate) gradually]
▲ 緩慢下降[slow crisis (lysis) of ]
▲ 一天天下降[be (become) lower day by day]
▲ 開(kāi)始降低[begin to remit]
▲ 降至正常[drop (was reduced) to normal]
▲ 已降至[have gone down (dropped) to]
▲ 回復(fù)到正常[return (revert) to normal]
▲ 由……降(升)至……[fall (elevate) from……to……]
▲ 維持在……水平[maintain at a level of……]
▲ 穩(wěn)定在……[stabilize at……]
▲ 熱退了[fever disappeared]
▲ 不超過(guò)[do not go up over (exceed)……]
▲ 在……和……之間波動(dòng)[fluctuate (vary) between……
and……]
▲ 在……至……范圍內(nèi)[range from……to……]
▲ 平均38.5℃[an average temperature of 38.5℃]
▲ 有39.2℃的體溫[have fever (a temperature) of 39.2℃]
5、癥狀的時(shí)間表示
•持續(xù)  ▲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
•超過(guò)(不到)[move than (less than)]
•……以前[two years ago]
•多在……時(shí)發(fā)生[usually between 3 and 5 PM]
•未發(fā)作過(guò)[be free of onsets (attacks) for 2 weeks]
6、癥狀的嚴(yán)重程度
•輕度[mild (slight)]
•中度[moderate]
•重度[severe (serious)]

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