实用医患对话 | 儿科医生如何询问病史
摘要: 儿科医生询问病史是通过系统性地收集儿童及其家庭的健康信息,包括孕期、分娩、发育、喂养、疫苗接种、既往疾病、家族史等,以支持临床评估与诊断的过程。
- 儿科病史采集涵盖孕期并发症、分娩方式、新生儿状况及发育里程碑等关键信息。
- 医生需了解儿童的喂养方式、辅食添加、断奶情况及营养补充(如维生素)使用情况。
- 家族史(如糖尿病、癌症)和过敏史对儿童疾病风险评估具有重要参考价值。
- 即使家长认为孩子健康,医生仍应主动询问近期感染、用药、手术及检查等情况。
- 开放式结尾问题(如“还有其他需要告诉我的吗?”)有助于发现潜在但未被提及的信息。

小白老师说:学英语这件小事,只要每天进步一点点就可以了,时间长了,你一样可以把大多数人甩在身后。医患英文对话,今天的主题是儿童病史采集,音频录的是美音。
点击这里轻轻打开音频**▼**
Pediatric Medical History 儿科医生如何询问病史
D = Doctor, M = Mother
D: Were there any complications during pregnancy, like diabetes, hypertension?
在怀孕期间,您有什么并发症吗,比如糖尿病,高血压?
M: No, not really. Only that I am blood group O negative, so I had to have lots of blood tests and I had to be induced.
没有,不过我是 O 型阴性血,所以我得接受很多血液检测,而且必须引产。
D: Was it a normal delivery? Or C section, forceps, suction?
是顺产吗?还是剖腹产?产钳助产?吸引分娩?
M: It was forceps. 用了产钳。

D: Did you have an epidural?
你是否有过脊髓硬膜外腔的注射?
M: Yes, I did. 是的,有过。
D: Did you have any missages before your pregnancy?
在怀孕以前流产过吗?
M: Yes, I had two. 是的,流产过两次。
D: Has your child had any vaccinations? What are they?
你的孩子是否已经打过疫苗?是什么疫苗?
M: She has had all the child vaccinations.
她打过所有的儿童疫苗。
D: Has your child’s development been normal? Can your child sit, smile, crawl, walk?
你孩子的发育正常吗?能坐、笑、爬和走吗?
M: Yes, it has. 是的,一切正常。
D: Can you tell me your child’s feeding history?
能够告诉我你孩子的喂养记录吗?
M: Normal progress. 正常的进度。
D: Is your child breast or formula fed? Have supplementary foods? Is your child weaned?
你的孩子是母乳还是奶粉喂养?添加辅食了吗?孩子断奶了吗?
M: She is on normal foods now, and only has a bottle of cow milk in the evenings and juice in a cup during the day.
她现在饮食正常,晚上喝一瓶牛奶,白天一杯果汁。
D: Does your child have any existing medical health problems?
你孩子有已经确诊的病吗?
M: No. 没有。
D: Is she taking any other medication for any other reason, for example, vitamins?
有没有因为其他原因吃药呢,比如维生素?
M: She takes child vitamin pills in the winter.
她冬天的时候吃儿童维生素。

D: Have there been any illnesses or physical problems in the last year?
过去一年她得过什么病或有任何身体问题吗?
M: No. 没有。
D: Has she had any infections or viruses recently?
最近是否有过细菌或病毒感染?
M: She had a slight cold a couple of months ago, nothing serious.
两个月前,她得过轻微的感冒,但是并不严重。
D: Do you have a family history of diabetes, heart problems, cancer or lung complaints?
家庭中是否有糖尿病、心脏病、癌症或呼吸疾病的病史?
M: Both her grandparents have diabetes, and her grandfather had lung cancer.
她祖父母都有糖尿病,而且她祖父还得过肺癌。
D: Has she had any surgery? What for?
她是否曾经做过手术?如果有,是什么原因?
M: No. 没有。
D: Does she have any allergies?
她对什么有过敏反应?
M: No. Not that I know of. 就我所知没有。
D: Has she had any medical tests recently?
她最近做过什么医疗检测吗?
M: No. 没有。
D: Is there anything you need to tell me, that you think will be useful?
你是否还有其他对病情有用的信息可以提供给我?
M: No. I don’t think I need to tell you anything else.
没有。我认为没有其他可以告诉您的了。
常见问题
儿科医生为什么要问母亲的怀孕和分娩情况?
因为孕期并发症(如糖尿病、高血压)、血型不合、分娩方式(如产钳助产)等可能影响新生儿健康和后续发育。
儿童病史中为什么要关注喂养和维生素摄入?
喂养方式和营养补充直接影响儿童生长发育,例如维生素D缺乏可能导致佝偻病,而过早或不当添加辅食可能引发过敏或消化问题。
家族病史在儿科问诊中有何作用?
某些疾病(如糖尿病、哮喘、遗传代谢病)具有家族聚集性,了解家族史有助于早期识别高风险儿童并进行针对性筛查或干预。
如果孩子看起来很健康,还需要详细询问病史吗?
是的,许多潜在问题(如轻度发育迟缓、隐性遗传病、环境暴露风险)可能无明显症状,系统问诊有助于全面评估健康状况。
参考资料
American Academy of Pediatrics - Pediatric History and Physical Examination
美国儿科学会推荐的儿科病史采集标准框架,涵盖产前、围产期、发育、家族史等核心内容。
实用医患对话 | 儿科医生如何询问病史
↗本文原始来源,提供真实医患英文对话示例及中文翻译。