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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)]
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