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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:英文病历全攻略(六)-现症史
    

英语病历书写(六)-现症史

六、现症史Present Illness
(1)他在1960年9月生了病;疲劳渐渐加重,周身不适,并且体重减轻。
He became ill in Sept. 1960, with gradually increasing fatigue, general malaise and loss of weight.
※疾病的发生
-开始头痛 started having the headaches
-开始发生紫绀 began having episodes of cyanosis
-开始感觉疲劳 began feeling tired
-变成稍一用力即会喘息 became breathless on the least exertion
-发觉开始过度疲劳 noted the onset of excessive fatigue
-晚餐时饮酒差不多一定会引起发作 a supper drink almost invariably provokes an attack
-不能恢复以前的那种活力 fail to regain one's previous vitality and vigor
-开始觉得比以前更加容易疲倦 began to fell more easily fatigued
ex1:The disease began (occurred ; started) 3 months ago. It progressed , slowly but steadily until today.
ex2: In the spring of 1958 he first noticed (noted; perceived; recognized) easy fatiguability.
※初发病型
ex1: He became increasingly subject to fits of temper.
ex2: He suddenly developed weakness in the right leg.
(2)她的膀胱过敏症消失,但在1960年秋天复发。
Her symptoms of bladder irritability subsided, but recurred in the autumn of 1960.
※病征
-有疼痛和已述的症状 pain plus the symptoms already mentioned
-想把症状和~关连起来 attempt to correlated symptoms with~
-症状自然消退 symptoms spontaneously regressed
-症状消失(并未缓和) symptoms disappeared (did not abate)
-症状忽缓忽急 symptoms waxed and waned from time to time
-不留意症状 give the symptoms no concern
-忽略( 不理) 症状 disregard (dismiss) symptoms
-对症状不甚留意 do not pay much attention to the symptoms
-对孩子们显得不关心、冷淡 one appeared uninterested and uninformed about one's children
-呕吐是~发病的前驱症状 vomiting heralded the onset of one's symptoms
-~的病有伤寒的样子 one's illness assumed the character of typhus
-再发(have a) relapse;recur; recurrence
-疾病无再发征象 no evidence of recurrent disease
-同一症候再发 the return of the same symptoms
ex1: He had (presented; developed; showed; manifested) mild symptoms of diphtheria.
ex2: There have been concurrent heartburn and eructation.
※无~症状
ex1: The carious tooth has persisted for years without clinical symptoms.
ex2: He continued remarkably free of symptoms except for aural discharge until Nov. 1961.
(3)他记得一年前,在同一季节里,有过一次同样的发作。
He remembered a similar attack a year before in the same season.
※发作
-一时性眩晕 transitory attacks of dizziness
-发作不规则 attacks are variable
-发作变了型态 the attacks changed pattern
-患急性关节炎 have acute attacks of arthritis
-发作多半在夜间发生 attacks occurred chiefly at night
-患2次肺炎 had 2 episodes of pneumonia
-发生癫痫样的发作 developed seizures of an epiletic nature
-发作前后觉得舒适 feel well between attacks
-平均继续了3~4分钟 lasted on average 3 to 4 minutes
-一年来没有发作 have been free of attacks for one year
-发作停止(消失,完全消失)了 attacks ceased ( subsided, clear up completely)
ex1: A similar attack appeared in the following morning. It ran the same course as the first one.
ex2: The most recent episode occurred approximately one month before his first visit to the clinic.
※发作时间
-B随A A is followed by B : B follows A
-A与B同时发生 A is associated with B
-和~有关系 have (make) relation to~
-和~不相关 have (make) no relation to~
-似乎与姿势、咳嗽、过度用力无关 appeared unrelated to position, coughing,or straining.
ex1: The attacks were preceded by 3 or 4 hour prodromes of nausea, abdominal distention, diarrhea or constipation, followed by 5 to 6 hour period of cramping abdominal pain and bile-stained vomiting, terminated by transient diarrhea.
ex2: The pain was described as being of a cramping nature and sometimes appeared to be related to the ingestion of cold water or milk.医学 全在.线提供www.med126.com
(4)每天服用pyrazinamide 4次,每次75mg.后,咳嗽减少,痰亦减半,热度
也降低。
With pyrazinamide, 75 mg. 4 times daily, there was improvement of cough, a 50 per cent decline in sputum, and a reduction of fever.
※症状的减轻和消失
-转佳 take a favorable turn ; take a turn for the better ; improve
-显著减轻 decrease drastically (markedly)
ex1: Such attacks usually subside promptly with rest, in an hour or so , sometimes in a few minutes.
ex2: The swelling of the legs disappeared within about a week.
(5)疼痛发生于饭后,便秘发生后,疼痛更加厉害,期间也较长。
The pain came on after meals and became more severe and lasted longer with the onset of constipation.
※症状的恶化
-恶化 take a bad turn ; take a turn for the worse; be aggravated (exacerbated)
-显著地恶化 became noticeably worse
-渐趋显著 became increasingly apparent
-黄疸总是恶化 have frequent exacerbations of jaundice
-病入膏肓 one's case is incorrigible
-病状时愈时犯 one's illness hangs in the balance
ex1: During the last 6 weeks he has observed progressive shortness of breath on exertion.
ex2: The pain was aggravated by exercise and alleviated somewhat by lying down.
(6)他的一般情形,一直没有变化。
His general condition continued without change.
※症状无变化
ex1: He remained about the same a yesterday.
ex2: His headache has persisted (continued) to date ( the present).

 

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