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1、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 fromhave an attack ofhave(fell)begin to fell a feeling (sens
2、ation) 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 b
3、e 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
4、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
5、 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 turn take a turn for the better improvemake favo
6、rable progress turn for the better change for the better be better 症状减轻 alleviatereducepalliate diminish ease(lighten) mitigate 症状消失 disappearsubsideregress clear up vanish dissolve die (fade) away relieve 症状加重 be (make,become,get) worse worsenbecome more severetake a turn for the worse be aggravate
7、dincrease in severity take a bad turnmake (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
8、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) fr
9、om 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 C an average temperature of 38.5C 有39.2 C 的体温have fever (a temperature) of 39.2 C 5 、症状的时间表示持续 lasted for 2 days have gone on for 1 month ha
10、ve 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(不至 U)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seve
11、re (serious)7、症状的其他描述方法部位be located (situated) in (over)位于 There is localized pain in 疼痛位于 n ear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
12、 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 skin of the left breast转移/放射转移到shift (migrate) to 放射至 Uradiate (travel,go,refer)to 从放射到radiate from to 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
13、in the left ear 耳聋 deafness (loss in hearing) 左耳聋 be deaf of the left ear 耳流脓 otorrhea (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) thenose(nasal dyspnea) 打喷涕和流涕 sneezing and nasal discharge 水样鼻涕 watery rhinorrhea 鼻出血 n
14、osebleed 咽喉痛 sore throat 口吃 stuttering口臭 ozostomia (saburra,halitosis) 张口困难 difficult (inability) to open the 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 asthenopi
