1、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 week2、症状出现的叙述有症状suffer from have an attack of have(fell) begin to fell a fe
2、eling (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 mea
3、ls 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 abr
4、uptly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ha
5、ng 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 steady4、病情变化描述症状好转 fell better than beforetake a favorable turntake a turn for the betterimprovemake favorable progres
6、sturn for the betterchange for the betterbe better症状减轻 alleviatereducepalliatediminishease(lighten)mitigate症状消失 disappearsubsideregressclear upvanishdissolvedie (fade) awayrelieve 医学.全.在线.网.站.提供症状加重 be (make,become,get) worseworsenbecome more severetake a turn for the worsebe aggravatedincrease in s
7、everitytake a bad turnmake (become) more seriousmake (become) heavier无变化 remain the same ascontinue without changebe identicalbe alikebe similarresemble时好时坏 wane and waxhang 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)
8、 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) fromto 维持在水平maintain at a level of
9、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) betweenand 在至范围内range fromto 平均 38.5an average temperature of 38.5 有 39.2的体温have fever (a temperature) of 39.25、症状的时间表示持续 lasted for 2 dayshave gone on for 1 monthhave continued for 10 hourslasted on the averag
10、e 3-5 hourslasted a variable time from 5 minutes to several hourslasted 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 weeks6、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 (ov
11、er)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 s
12、kin 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 fromto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 (
13、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
14、 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ophthalmo
15、copia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
16、) 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 leuk
17、orrhea 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 menopausal50 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）polyhydram
18、nios (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
19、 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)
20、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
21、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 waken
22、ed 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）fr
23、equency(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)
