第三节 现病史

一、主要内容

现病史（history of present illness）是住院病历书写的重点内容，应结合问诊内容，经整理分析后，围绕主诉进行描写，主要内容应包括以下几点。

1．起病情况：患病时间、起病缓急、前驱症状、可能的病因和诱因。

2．主要症状的特点：应包括主要症状出现的部位、性质、持续时间、程度以及加重或缓解的因素。

3．病情的发展与演变：包括主要症状的变化以及新近出现的症状。

4．伴随症状：各种伴随症状出现的时间、特点及其演变过程，各伴随症状之间，特别是与主要症状之间的相互关系。

5．记载与鉴别诊断有关的相关资料

6．诊疗经过：何时、何处就诊，做过何种检查，诊断何病，经过何种治疗，所有药物名称、剂量及效果。

7．一般情况：目前的食欲、大小便、精神、体力、睡眠、体重改变等情况。

二、注意事项

1．凡与现病直接有关的病史，虽年代久远亦应包括在内。

2．若患者存在两个以上不相关的未愈疾病时，现病史可分段叙述或综合记录。

3．凡意外事件或可能涉及法律责任的伤害事故，应详细客观记录，不得主观臆测。

4．现病史书写应注意层次清晰，尽可能反映疾病的发展和演变。

5．现病史描写的内容要与主诉保持一致性。

三、现病史中常用英文句型

she developed...in....

她在……发生（出现）……（症状）

She went to..., received...to treat her...

她去……（医院、诊所），接受……治疗

Two days prior to admission, he noted an abrupt onset of....

他入院前两天，发现（出现）显著……（症状）

He began having difficulty...（doing）when...（doing）

在……（时候或做……事的时候）出现困难

He had trouble...（doing）, and subsequently in...（doing）

他因不能……，所以不能（做）……

He then began to have problems...（doing）

因此他开始（做）……困难

have problems with...

做……困难

got worse with increasing...

随着……增加，变得更困难

...in...gradually increased up to...and to a lesser extent involved his....

在……, ……（症状）逐渐加重，至少涉及他的……

...have worsened in the last...months

在过去……月，（症状）逐渐加重

having pain in...radiating down to...

……（部位）出现疼痛，并放散到……（部位）

She was prescribed...

给予她……（药、建议、治疗等）

the acute onset of...which was more marked on...（doing）, but was present to a lesser extent when...（doing）.

在……的时候（症状）急性发作，（做）……的时候（症状）逐渐加重，但是（做）……的时候（症状）减轻。

...have continued to progress to the present time.

……（症状）发展（进展）到现在。

was graded as...

分级为……

The residual weakness on the left had completely resolved and he reported no new weakness.

右侧残留的无力完全消失，并且没有新的无力。

Her...continued to deteriorate.

她的（病情）继续恶化。

Her balance deteriorated and on one occasion she fell in the shower.

她的平衡能力变差，一次洗澡时跌倒。

the...became constant

（症状）持续

He saw an outside neurologist who started him on...（drugs）without improvement.

他去看外面的神经病学家，给他用……药，但是没有改善。

四、现病史中常用英文表述

1．诱因

无诱因下 [with no inducing factors]

无明显诱因下 [under no obvious predisposing causes]

感冒1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）...

have a temperature（become feverish）[发热]

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]

偶尔 [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]

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

turn for the better

improve

change for the better

make favorable progress

be better

症状减轻

alleviate

diminish

reduce

ease（lighten）

palliate

mitigate

症状消失

disappear

vanish

subside

dissolve

regress

die（fade）away

clear up

relieve

症状加重

be（make, become, get）worse

increase in severity

worsen

take a bad turn

become more severe

make（become）more serious

take a turn for the worse

make（become）heavier

be aggravated

无变化

remain the same as...

be alike

continue without change

be similar

be identical

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 p.m.]

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）]

7．症状的其他描述方法

部位

位于 [be located（situated）in（over）]

疼痛位于 [There is localized pain in...]

在……附近 [near...]

局限于 [be localized to（in, over）]

局限于 [be limited（confined）to]

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 skin 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 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 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）the nose（nasal dyspnea）]

打喷嚏和流涕 [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 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 [ophthalmocopia]

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）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）[regular（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 leukorrhea or whites）]

外阴瘙痒 [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 menopausal]

50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 of membranes）]

羊水过多（少）[polyhydramnios（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 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 [puerperal 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）]

病程中的一般情况

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8千克 [a 8 kilograms 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 wakened at night because of...]

失眠 [have insomnia]

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]

含黏液的水样便 [watery stools containing mucus]

便秘（腹泻）[constipation（diarrhea）]

排尿困难 [difficulty in micturition]

尿频（急）[frequency（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）]