科研教学 > 医学英语
皮肤科英文查房手册连载(17):现病史的书写技巧 
皮肤科医师之家       2013年8月6日        阅读数:569        字体:      

  History of present illness: the most crucial part of the entire database. The questions are guided by the differential diagnosis. The doctor begins to consider what the patient mainly complained about, as well as the clinician’s knowledge of typical disease
patterns and their natural history. The duration and character of the primary complaint, associated symptoms, and exacerbating/
relieving factors should be recorded. Sometimes, the history will be convoluted and lengthy, with multiple diagnostic or therapeutic interventions at different locations. When reviewing prior records, it is often useful to review the primary data(biopsy reports,
serologic evaluations) rather than to rely on a diagnostic label applied by someone else.

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
第一节: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
第二节: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
第三节: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
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