英语医学

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 by3、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) theleft 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 ofclots]▲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) vaginalbleeding]▲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 andlasted 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 ofmembranes)]▲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)]。