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您现在的位置: 医学全在线 > 医学英语 > 英语教学 > 英文病历 > 正文:简明病历书写手册第三章:现病史[History of present illness (HPI/PI)]
    

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)]

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