描述病史的概况之后，需进一步叙述病人的症状和临床治疗过程。应重点注意以下问题:(1)主要说明典型的症状、并发症、诊断与治疗,避免无关的材料,更没有必要把每天的血压、体温、化验结果等统统列出;(2)说明特殊的检查方法，并说明检查结果;(3)说明用药剂量，如果比正常剂量大或小均应标明;(4)说明治疗效果；症状减轻与否?是否有并发症?是否在预料之中?(5) 说明治疗的结果：病人是存活还是死亡?病人的现状如何?病人还要接受哪些处置等等。下面为各内容的典型写作句式。

(1) 症状描述

此部分主要用一般过去时或过去完成时表达。

例一：

主诉在当地一酒吧共进午餐15至30分钟后，突然出现弥漫性班疹。二人都感到燥热并大便2到3次。无呼吸系统症状，其他系统亦均正常。二者均无过敏史。唯一值得注意的药物史是二者曾偶尔使用沙丁胺醇治疗轻徽哮喘。

They described the acute onset of a diffuse rash 15 to 30 minutes after they had lunched together in a local pub. Both felt hot and had passed two or three bowel motions. They had no respiratory symptoms and were otherwise systemically well. Neither had ever experienced an allergic reaction and the only medical history of note was that both used occasional salbutamol for mild asthma.

例二：

一患者，女性，29岁，第3次妊娠分娩4周后无任何并发症，现下背部疼痛一周。疼痛首次出现在她抱孩子时，并逐渐恶化。入院3天前,左侧坐骨神经痛，并伴有肛周和阴道麻木。症状最初由妊娠和分娩引起，出现尿潴留时被收治入院。

A woman aged 29 was seen four weeks after a third uncomplicated pregnancy and delivery with a 1-week history of lower back pain. The pain first occurred when she lifted her baby but had been getting progressively worse. In the three days before admission she had also experienced left-sided sciatica and perianal and vaginal numbness. The symptoms were initially attributed to the pregnancy and childbirth， but the paticnt was referred to hospitai when she developed urinary retention.

(2) 检查

例一：

经检查，二人均有弥漫性红斑疹，遍及面部、躯干和四肢。由于症状未见好转，到院就诊。临床检查显示鞍区麻木，肛肌紧张性降低，两侧踝反射无力。

On examination, both had a diffuse erythematous rash widely spread over the face, torso and limbs. When symptoms did not resolve she was referred to hospital where clinical examination revealed saddle anaesthesia, reduced and tone and absent ankle reflexes bilaterally.

例二:

核磁共振显示腰5、骶1椎间盘较大，髓核脱出。

Magnetic resonance imaging (MRI) displayed a large central disc prolapse at L5- S1 level.

(3) 治疗

此部分常用被动语态。

例一：

静脉滴注扑尔敏和氢化可的松。

They were given intravenous chlorpheniramine, hydrocortisone and fluids.

例二：

对病人行紧急显微椎间盘切除术。

The patient underwent emergency microdiscectomy.

(4) 治疗效果

例一：

静脉注射氢化可的松和扑尔敏后，病人又接受观察数小时，情况好转后出院。

After he had been given intravenous hydrocortisone and chlorpheniramine he was observed for a few hours and discharged when he improved.

例二：

病人术后疼痛消失，泌尿系统症状明显好转后分娩，无并发症发生。然而一年后随访，病人仍诉骶部惑觉迟钝。

Postoperatively the pain disappeared, her urinary symptoms greatly improved and she went to have an uncomplicated delivery. At one-year follow-up, however, she continued to report reduced sensation in the sacral area.

责任编辑：admin