現(xiàn)病史書寫的重點(diǎn)包括：
一、主訴中癥狀的詳細(xì)描述；
二、疾病的發(fā)展過程；
三、診療經(jīng)過；
四、目前的一般情況。
1、誘因
•無誘因下[With no inducing factors]
•無明顯誘因下[Under no obvious predisposing causes]
•感冒一周后[After getting (catching) common cold for 1 week]
2、癥狀出現(xiàn)的敘述
•有……癥狀
▲suffer from
▲ have an attack of
▲ have(fell)
▲ begin to fell
▲ a feeling (sensation) of……
▲ complain (of)
▲ ……sensation (feeling) in (of) ……
▲ [發(fā)熱]have a temperature (become feverish)
•在……情況下發(fā)生
▲ 活動時呼吸困難[dyspnea on exertion]
▲ 躺下后即出現(xiàn)咳嗽[Cough occurs soon after lying]
•與……有（無)關(guān)
▲ 與……有關(guān)[be associated with]
▲ 與……有關(guān)[have (make) relation to]
▲ 與……無關(guān)[have (make)no relation to]
•在……情況下加重（減輕)
▲ 餐后加重[become worse after taking meals]
▲ 站立后緩解[be relieved by standing up]
▲ 隨呼吸和咳嗽而加重[become more severe with breathing and cough]
•伴有……
▲ be accompanied by
3、起病方式
•急性腹痛[acute abdominal pain]
•慢性低熱[chronic lower fever]
•暴發(fā)性發(fā)病[the onset was fulminating]
•驟起胸痛[an explosive onset of chest pain]
•突然起病伴高熱[the onset was sudden with high fever]
•突發(fā)突止[attacks began and ended abruptly]
•因……而突然起病[the attack is precipitated by……]
•很快發(fā)生暈厥[syncope occured rapidly]
•逐漸出現(xiàn)咳嗽咳痰[gradual onset of cough and sputum]
•偶而[occasionally (sporadically, accidentally)]
•反復(fù)胸悶心悸[recurrent (bouts of) chest discomfort and palpitation]
•一過性發(fā)作[transitory attack]醫(yī).學(xué).全.在線.網(wǎng).站.提供
•連續(xù)胸痛[chest pain continually]
•時重時輕[waned and waxed]
•時好時壞[hang in the balance]
•不停地咳嗽[have a fit of cough]
•發(fā)作性呼吸困難[paroxysmal short of breath]
•頻繁咳嗽[cough frequently (very often)]
•持續(xù)性（間歇性)[persistent (intermittent)]
•頻發(fā)胸痛[frequent episodes of chest pain]
•持續(xù)不變[be steady]
4、病情變化描述
•[癥狀好轉(zhuǎn)] ▲fell better than before
▲take a favorable turn
▲take a turn for the better
▲improve
▲make favorable progress
▲turn for the better
▲change for the better
▲be better
•[癥狀減輕] ▲alleviate
▲reduce
▲palliate
▲diminish
▲ease(lighten)
▲mitigate
•[癥狀消失] ▲disappear
▲subside
▲regress
▲clear up
▲vanish
▲dissolve
▲die (fade) away
▲relieve醫(yī)學(xué).全.在線.網(wǎng).站.提供
•[癥狀加重] ▲be (make,become,get) worse
▲worsen
▲become more severe
▲take a turn for the worse
▲be aggravated
▲increase in severity
▲take a bad turn
▲make (become) more serious
▲make (become) heavier
•[無變化] ▲remain the same as……
▲continue without change
▲be identical
▲be alike
▲be similar
▲resemble
•[時好時壞] ▲wane and wax
▲hang in the balance
•[體溫/血壓升降]
▲ 升至[rise (go up) to ]
▲ 已升至[have risen (gone up) to ]
▲ 從……升至……[go up from …… to……]
▲ 升至[be elevated to]
▲ 迅速下降[fall (decline, abate) abruptly]
▲ 驟降（升)[sudden drop (elevation)]
▲ 漸降（升)[fall (elevate) gradually]
▲ 緩慢下降[slow crisis (lysis) of ]
▲ 一天天下降[be (become) lower day by day]
▲ 開始降低[begin to remit]
▲ 降至正常[drop (was reduced) to normal]
▲ 已降至[have gone down (dropped) to]
▲ 回復(fù)到正常[return (revert) to normal]
▲ 由……降（升)至……[fall (elevate) from……to……]
▲ 維持在……水平[maintain at a level of……]
▲ 穩(wěn)定在……[stabilize at……]
▲ 熱退了[fever disappeared]
▲ 不超過[do not go up over (exceed)……]
▲ 在……和……之間波動[fluctuate (vary) between……
and……]
▲ 在……至……范圍內(nèi)[range from……to……]
▲ 平均38.5℃[an average temperature of 38.5℃]
▲ 有39.2℃的體溫[have fever (a temperature) of 39.2℃]
5、癥狀的時間表示
•持續(xù) ▲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
•超過（不到)[move than (less than)]
•……以前[two years ago]
•多在……時發(fā)生[usually between 3 and 5 PM]
•未發(fā)作過[be free of onsets (attacks) for 2 weeks]
6、癥狀的嚴(yán)重程度
•輕度[mild (slight)]
•中度[moderate]
•重度[severe (serious)]
