描述病史的概況之后，需進一步敘述病人的癥狀和臨床治療過程。應(yīng)重點注意以下問題:(1)主要說明典型的癥狀、并發(fā)癥、診斷與治療,避免無關(guān)的材料,更沒有必要把每天的血壓、體溫、化驗結(jié)果等統(tǒng)統(tǒng)列出;(2)說明特殊的檢查方法，并說明檢查結(jié)果;(3)說明用藥劑量，如果比正常劑量大或小均應(yīng)標(biāo)明;(4)說明治療效果；癥狀減輕與否?是否有并發(fā)癥?是否在預(yù)料之中?(5) 說明治療的結(jié)果：病人是存活還是死亡?病人的現(xiàn)狀如何?病人還要接受哪些處置等等。下面為各內(nèi)容的典型寫作句式。
(1) 癥狀描述
此部分主要用一般過去時或過去完成時表達。
例一：
主訴在當(dāng)?shù)匾痪瓢晒策M午餐15至30分鐘后，突然出現(xiàn)彌漫性班疹。二人都感到燥熱并大便2到3次。無呼吸系統(tǒng)癥狀，其他系統(tǒng)亦均正常。二者均無過敏史。唯一值得注意的藥物史是二者曾偶爾使用沙丁胺醇治療輕徽哮喘。
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歲，第3次妊娠分娩4周后無任何并發(fā)癥，現(xiàn)下背部疼痛一周。疼痛首次出現(xiàn)在她抱孩子時，并逐漸惡化。入院3天前,左側(cè)坐骨神經(jīng)痛，并伴有肛周和陰道麻木。癥狀最初由妊娠和分娩引起，出現(xiàn)尿潴留時被收治入院。
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) 檢查
例一：
經(jīng)檢查，二人均有彌漫性紅斑疹，遍及面部、軀干和四肢。由于癥狀未見好轉(zhuǎn)，到院就診。臨床檢查顯示鞍區(qū)麻木，肛肌緊張性降低，兩側(cè)踝反射無力。
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:
核磁共振顯示腰5、骶1椎間盤較大，髓核脫出。
Magnetic resonance imaging (MRI) displayed a large central disc prolapse at L5- S1 level.
(3) 治療
此部分常用被動語態(tài)。
例一：
靜脈滴注撲爾敏和氫化可的松。
They were given intravenous chlorpheniramine, hydrocortisone and fluids.
例二：
對病人行緊急顯微椎間盤切除術(shù)。
The patient underwent emergency microdiscectomy.
(4) 治療效果
例一：
靜脈注射氫化可的松和撲爾敏后，病人又接受觀察數(shù)小時，情況好轉(zhuǎn)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：
病人術(shù)后疼痛消失，泌尿系統(tǒng)癥狀明顯好轉(zhuǎn)后分娩，無并發(fā)癥發(fā)生。然而一年后隨訪，病人仍訴骶部惑覺遲鈍。
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.
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