英语医学.doc

英语医学病历书写手册第三章:现病史[History of present illness (HPI/PI)]
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医学.全.在线.网.站.提供
•[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)]
7、症状的其他描述方法
•[部位] ▲be located (situated) in (over)[位于]
▲There is localized pain in……[疼痛位于]
▲near……[在……附近]
▲be localized to (in, over)[局限于]
▲be limited (confined) to[局限于]
•[表示部位的介词]
▲心尖部，表示小的部位或点[at the apex]
▲上腹部，表示大的部位[in the upper abdomen]
▲在左下肢，表示皮肤表面上（下）的病变[on (beneath) the
left lower limb]
▲在右肺，表示正上方的相应体表部位[over the right lung]
▲嘴上（下）方，表示高低或上下的位置关系[above (below)
the mouth]
▲左乳皮下[under the skin of the left breast]
•[转移/放射]
▲转移到……[shift (migrate) to……]
▲放射到……[radiate (travel,go,refer)to……]
▲从……放射到……[radiate from……to……]
•[耳鼻咽喉及口腔症状]
▲耳痛[otalgia (pain of ears)]
▲耳鸣[tinnitus (ears ring)]
▲耳鸣[a buzzing (ringing,singing) in the ears]
▲左耳有耳鸣感[a buzzing sensation in the left ear]
▲耳聋[deafness (loss in hearing)]
▲左耳聋[be deaf of the left ear]
▲耳流脓[otorrhea (otopyorrhea)]
▲耳出血[otorrhagia]
▲耳垢[cerumen (earwax)]
▲耳血肿[othematoma]
▲鼻塞[nasal obstruction]
▲不能用鼻呼吸[be unable to breathe through (by) the nose
(nasal dyspnea)]
▲打喷涕和流涕[sneezing and nasal discharge]
▲水样鼻涕[watery rhinorrhea]
▲鼻出血[nosebleed]
▲咽喉痛[sore throat]
▲口吃[stuttering]
▲口臭[ozostomia (saburra,halitosis)]
▲张口困难[difficult (inability) to open the mouth]
▲张口（吞咽、嚼）困难[difficult in opening the mouth
(swallowing，masticating)]
▲咽下困难[dysphagia]
▲流涎多[have excessive salvation]
•[眼科及牙科症状]
▲眼睑浮肿[eyelid edema]
▲眼痛[pain in the eyes]
▲视边模糊[blurring of vision (blurred vision)]
▲过度流泪[excessive tearing (watering)]
▲视疲劳[asthenopia (visional tired)]
▲视力减退[hypopsia (diminution of vision)]
▲视力衰弱[ophthalmocopia]
▲远（近）视力模糊[indistinct distant (near) vision]
▲失明[loss of vision]
▲搏动性牙痛[throbbing pain of tooth (odontalgia)]
▲牙龈出血[gingival bleeding]
▲牙龈萎缩（增生）[gingival atrophy(hypertrophy)]
▲牙周溢脓[peripyema]
•[妇产科症状]
▲月经过多[excessive menstrual flow (menorrhagia)]
▲月经多并伴血块[experience menorrhagia with passage of
clots]
▲经量少（中等、多）[mild (moderate,heavy) menses]
▲月经过少[hypomenorrhea]
▲阴道出血[vaginal bleeding(colporrhagia)]
▲阴道大出血[massive (profuse) vaginal bleeding]
▲无痛性（性交后）阴道出血[painless(postcoital) vaginal
bleeding]
▲阴道干燥[colpoxerosis]
▲月经规则（不规则）[rugular (irregular) menstrual cycle]
▲月经周期26天，持续4天[menstrual periods of 26 days and
lasted 4 days]
▲白带增多[leukorrhagia (profuse leukorrhea or whites)]
▲外阴搔痒[pruritus of vulva]
▲外阴湿疹（白斑）[eczema (leukoplakia) of vulva]
▲绝经[amenorrhea]
▲停经[menopause]
▲停经3年[3 years post menopausal]
▲50岁停经[Passed menopause at age 50]
▲经前（期）痛[pain before (during) the flow]
▲预产期[expected date of confinement]
▲见红和破水[show and amniotic fluid escaped (rupture of
membranes)]
▲羊水过多（少）[polyhydramnios (oligohydramnios)]
▲月经期水肿[menstrual edema]
▲月经失调[menstrual disorder]
▲性欲正常（减退）[normal(decreased) libido]
▲无性欲[loss of libido]
▲性功能障碍[sexual disorder]
▲性变态[paraphilia]
▲性要求高（低）[be oversexed(undersexed)]
▲性感不快[dypareunia]
▲性欲亢进（减退）[hypersexuality (hyposexuality)]
▲产程[stage of labor]
▲产程延长[prolonged labor]
▲产道裂伤（损伤）[laceration (injury) of birth canal]
▲产后腹痛（出血，尿潴留，子痫）[postpartum tormina
(hemorrhage,retention of urine, eclampsia)]
▲产前出血[antepartum hemorrhage]
▲产前子痫[prenatal eclampsia]
▲产前检查[prenatal examination]
▲产褥热[puerperal fever]
▲产褥期护理[pureperal care]
▲妊娠呕吐[vomiting of pregnancy (hyperemesis gravidarum)]
▲妊娠反应[pregnancy reaction]
▲妊娠高血压（水肿）[gestation hypertension (edema)]
•[病程中的一般情况]医学全.在线网.站.提供
▲一般情况尚可（一般、差）[general condition is fair (ordinary, bad)]
▲胃纳佳（差）[have a good (poor) appetite]
▲过度进食[eat too much (overeat, eat heavily)]
▲过少进食[eat poorly (take little food)]
▲无食欲[have no appetite]
▲食欲减退[appetite decreases]
▲口渴[feel thirsty]
▲大量饮水[drink water generously]
▲体重增加[gain in weight]
▲体重增加8公斤[a 8 kilograms weight gain (gain 8 kilograms)]
▲体重减轻[loss of weight (weight loss)]
▲体重稳定不变[body weight is stable (unchanged, maintained)]
▲睡眠障碍[somnipathy]
▲睡眠不足[lack (want) of sleep]
▲不易入睡[have trouble getting to sleep]
▲容易入睡[fall into a sleep very easily]
▲睡眠过度[hypersomnia]
▲睡行症[sleep walking]
▲嗜（贪）睡[somnolence (be fond of sleep)]
▲夜晚因……而易醒[easily wakened at night because of……]
▲失眠[have insomnia]医学.全在.线
▲睡眠差（好）[sleep is poor (good)]
▲消化不良[dyspepsia (have bad digestion)]
▲大（小）便通畅[stool (urination) is easy and smooth(unobstructed, clear)]
▲每日2次大便[have two stools daily]
▲含粘液的水样便[watery stools coutaining mucus]
▲便秘（腹泻）[constipation (diarrhea)]
▲排尿困难[difficulty in micturition]
▲尿频（急）[frequency(urgency) of micturition]
▲尿痛[micturition pain]
▲少尿（无尿、多尿）[oliguria (anuria, polyuria)]
▲大便失禁[fecal incontinence]
▲小便失禁[incontinence of urine]
▲精神不振[lassitude]
▲精神紧张（抑郁）[mental stress (depression)]
▲精神混乱[confusion]
▲精神失常[amentia (mental state is bad)]
▲精神状态正常[orthophrenia (mental state is good)]
▲体力旺盛（不足，正常）[hypersthenia (hyposthenia, euthesia)]