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住院病历的英汉对照

POMR(Problem-OrientedMedicalRecords)表格式住院病历

Biographicaldata:

一般项目:

NameAgeSexMaritalstatusNativityRace

姓名年龄性别婚否籍贯民族

OccupationDateofadmissionInformantHistory

职业入院日期病史叙述者病史

Chiefcomplaint

主诉

Historyofpresentillness

现病史

Pasthistory

既往史:

Previoushealthstatus:wellordinarybadInfectiousdiseases

平素健康状况:良好一般较差传染病史

ImmunizationsAllergies:NYclinicalmanifestation

预防接种史过敏史无有临床表现

allergen:Trauma:Surgery:

过敏原外伤史手术史

Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpostive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)

系统回顾:(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过)

Respiratorysystem:

呼吸系统

Sorethroatchroniccoughsputumhemoptysiswheezing

咽痛慢性咳嗽咳痰咯血哮喘

dyspneachestpain

呼吸困难胸痛

cadiovascularsystem:

循环系统

Palpitationdyspneaonexertionhemoptysissyncope

心悸活动后气促咯血晕厥

edemaoflowerlimbsprecordialpainhypertention

下肢水肿心前区疼痛高血压

Digestivesystem:

消化系统

Anorexiasourregurgitationbelchingnauseavomitting

食欲减退反酸嗳气恶心呕吐

abdominaldistentionabdominalpainconstipationdiarrhea

腹胀腹痛便秘腹泻

hematemesismelenahematocheziajaundice

呕血黑便便血黄疸

Urinarysystem:

泌尿系统

Lumbagofrequentmicturitionurgentmicturitionurodynia

腰痛尿频尿急尿痛

dysuriahematurianocturiapolyuriaoliguriafacialedema

排尿困难血尿夜尿多尿少尿面部水肿

Hematopoieticsystem

造血系统

Fatiguedizzinessblurredvisiongingivalbleedig

乏力头昏牙龈出血

subcutaneoushemorrhageostealgiaepistaxis

皮下出血骨痛鼻衄

Metabolicandendocrinesystem:

代谢及内分泌系统

Excessiveappetiteanorexiasweatscoldintolerance

食欲亢进食欲减退多汗畏寒

polydipsiatremorhandschangeofcharacterobviousobesity

多饮双手震颤性格改变显著肥胖

emaciationhirsutismhairlosingpigmentation

消瘦多毛毛发脱落色素沉着

changofsexualfunctionamenorrhea

性功能改变闭经

Musculoskeletalsystem

肌肉骨骼系统

Floatingarthralgiaarthraligaswellingofjoints

游走性关节痛关节痛关节红肿

deformiteiesofjiontsmyalgiaatrophyofmuscle

关节变形肌肉痛肌肉萎缩

Nervoussystem

神经系统

Dizzinessheadachevertigosyncopedegenerationofmemory

头昏头痛眩晕晕厥记忆力减退

visualdisturbanceinsomniadisturbanceofconsciousness

视力障碍失眠意识障碍

tremorspasmparalysisparesthesia

颤动抽搐瘫痪感觉异常

Personalhistory:

个人史

BirthplaceOccupationsexualhistorysmokingNY

出生地职业冶游史吸烟无有

aboutyearsaveragepiecesperdayceasedforyears

约年平均支/日戒烟年

alcoholintakeNoccasionalfrequentaboutyears

嗜酒无偶有经常约为年

averagemlperdayothers

平均ml/日其他

Maritalhistory:

婚姻史:

Marryingagecompanion’sstateofhealth

结婚年龄配偶健康状况

MenorrheaandChildbearing:

月经及生育史

Menarcheagecyclelastingfordaysdateoflastperiod

初潮每次持续时间末次月经时间

(ageofmenopause)

绝经年龄

Amountofflow:littlenormallargemenstrualpain:NY

经量少正常多痛经无有

cycle:regularirregularpregnancytimesnaturallabor

经期规则不规则妊娠次顺产

timesabortionstimesprematuredeliverytimes

胎流产胎早产胎

stillbirthstimesdifficultlaboranditscondition

死产胎难产及病情

Famillyhistory(payattentiontothecongenitaldiseasesand

communicablediseasesandcommunicabledieasesrelatedtothepaitent

家族史(注意与患者现病有关的遗传病和传染性疾病)

Father:stillaliveillnessdiedcauseofdeathsmother:

父:健在患病已故死因母stillaliveillnessdiedcauseofdeathsiblings:others:

健在患病已故死因兄弟姐妹子女其他

Physicalexamination体格检查

Vitalsigns生命体征:

Temperature体温

pulse脉搏/min次/分

respiration呼吸/min次/分

B.P血压mmHg

GeneralAppearance一般状况:

Development发育:

ortho-sthenictype正常

asthenictype不良

sthenictype超常

nutrition营养:

well良好

fairly中等

poor不良

cachexia恶病质

Facialfeatures面容:

normal无病容

acute急性

chronic慢性病容

others其他

Expression表情:

natural自知

painful痛苦

anxious忧虑

dreadful恐惧

indifferent淡漠

Position:activesemi-recumbentothers

体位:自主半卧位其他

Gait:normalabnormal

步态正常不正常

Conciousness:awaresomnolenceconfusionstuporcoma

神志清楚嗜睡模糊昏睡昏迷

deliriumcoppperatio;wellbadly

谵妄配合检查合作不合作

Mucocutaneouscolor:normalredpalecyaosisstainted

皮肤粘膜色泽无病容潮红苍白紫绀

yellowpigmentationlesions:NY(typeanddistribution)

黄染色素沉着皮疹无有(类型及分布)

Subcutaneoushemorrhange:NY(typeanddistribution)

皮下出血无有(类型及分布)

Hair:normalreducededema:NY(positionanddegree)

头发分布正常减退水肿无有(部位及程度)

Hepaticpalm:NYspiderangionma:NY(positionnumbers)others:

肝掌无有蜘蛛痣无有(部位数目)其他

Lymphnodes:

淋巴结

Superficiallymphnodes:non-swellingswelling(positionandcharacteristics)

全身淋巴结肿大无肿大肿大(部位及特征)

Head:cranium:size:normallargesmalldeformity:

头部头颅大小正常大小畸形

NY(coxycephalysquaredskulldeformingskull)

无有(尖颅方颅变形颅)

Others:tendernessmasssunk(position)

其他异常:压痛包块凹陷(部位)

Eyeseyelid:normaledemaptosistrichiasisconjunctive:

眼睑正常水肿下垂倒睫结膜

normalhyperemiaedemahemrrhage

正常充血水肿出血

eyeball:normalproptosisdepressiontremor

眼球正常突出凹陷震颤

motiondysfunction(leftright)

运动障碍

Sclera:normalyellowcornea:normalabnormal(leftright)

巩膜无黄染有黄染角膜正常异常(左右)

Pupils:equalroundnesssamesizeunequalleftcm

瞳孔等圆等大不等左cm

reactiontolight:normaldelay(leftright)disappear(leftright)对光反射正常迟钝(左右)消失(左右)

Others:

其他

Ears:auricle:normaldeformityfistulaothers(leftright)

耳耳廓正常畸形瘘管其他(左右)

excretionsofexternalauditorycanal:NY(leftrightfeature)

外耳道分泌物无有(左右性质)

Tendernessofmastoid:NYaudationdysfunction:NY(leftright)

乳突压痛无有听力粗试障碍无有(左右)

Nose:shape:normal:abnormal()otherabnormalities:NY

鼻外形正常异常()其他异常无有

Nosalalaflapobsructionexcretionsnasalsinustenderness:

鼻翼扇动鼻塞分泌物鼻旁窦压痛

NY(position)

无有(部位)

Mouthlips:redsyanosispaleherpesfissuremucosa:normal

口唇红润发绀苍白疱疹皲裂粘膜正常

abnormal(palepetechia)

异常(苍白出血点)

Openingofparotidglandduct:normalabnormal(swelling

腮腺导管开口正常异常(肿胀

suppurativeexcretions)

脓性分泌物)

Tongue:normalabnormal(coveringstremorleaningtoleftorright)

舌正常异常(舌苔伸舌震颤向左、向右偏斜)

Gums:normalswellingpusoverflowhemorrhagepigments

牙龈正常肿胀溢脓出血色素沉着

leadlinetooth:regularedentulouscariousteeth

铅线牙列齐缺牙—|—龋齿—|—

Tonsils:pharynx:voice:normalhoarse

扁桃体咽声音正常嘶哑

Neck:resistence:NYcarotidarterypulsation:normalincreased

颈部抵抗感无有颈动脉搏动正常增强

decreased(leftright)jugularvein:normaldistention

减弱(左右)颈静脉正常充盈

highdistentiontrachea:middledeviationto(leftright)

怒张气管正中偏移(向左向右)

Hepatojugularreflux:(-)(+)thyroid:normalswellingdegree

肝颈静脉回流征:(-)(+)甲状腺正常肿大度

Symmetry对称

Dominanceinoneside:spreadingnodular:softhardothers:NY

侧为主弥漫性结节性质软质硬其他无有

(tendernesstremorbruits)

(压痛震颤血管杂音)

Chesttopography:normalbarrelchestpigeonchestfunnelchest

胸部胸廓正常桶状胸鸡胸漏斗胸

flatchestbulgingorretraction(leftright)

扁平胸膨隆或凹陷(左右)

bulgingintheprecordialregiontendernessofsternum

心前区膨隆胸骨压痛

Breast:normalsymmetricalabnormal:leftright(gynecomastia

乳房正常对称异常左右(男乳女化

masstendernessexcretionsofnipples)

包块压痛乳头分泌物)

Lung

Inspection:movementofrespiration:normalabnormal:left

视诊呼吸运动正常异常左

right(increaseddecreased)

右(增强减弱)

Intercostalspace:normalwidenarrow(position)

肋间隙正常增宽变窄(部位)

Palpation:vocalfremitus:normalabnormal:leftright(increased

触诊:语颤正常异常左右(增强

decreased)pluernalfrictionrubs:NY(position)

减弱胸膜摩擦感:无有(部位)

Subcutaneouscrepitus:NY(posotion)percussion:resonance

皮下捻发感无有(部位)叩诊正常清音

abnormaldullnessflatnesshyperresonancetympany

异常叩诊音浊音实音过清音鼓音

Lowerborders:scapularline:rightintercostalspace,left

肺下界肩胛线右肋间左

intercostalspaceRangeofmobility:rightcm,leftcm

肋间移动度右cm,左cm

Dusculation:breathregularirregular

听诊呼吸规整不规整

Breathsound:normalabnormal(feature,position)

呼吸音正常异常(性质,部位描写)

Rale:NY:ronchi:sonoroussibilant

啰音:无有:干性鼾音哨笛音

Moistrales:coarsemediumfineralescrepitus

湿性大中小水泡音捻发音

Vocalconduction:normalabnormal:reducedincreased(position)

语音传导正常异常减弱增强(部位)

Plueralfrictionrubs:NY(position)

胸膜摩擦音无有(部位)

Heart心

Inspection:bulginginprecordialregion:NYapeximpulse:

视诊心前区隆起无有心尖搏动

normalunseenincreaseddiffusingposition:normal

正常未见增强弥散心尖搏动位置正常

deviation(thedistancefrommidclavicularlinecm)

移动(距左锁骨中线内外厘米)

Otherprecordialpulsations:NY(position)

其他部位搏动无有(部位)

Palpation:apeximpulse:normalincreasedthrustunclear

触诊心尖搏动正常增强抬举感触不清

thrills:NY(positionperiod)percardialfrictionrubs:NY

震颤无有(部位时期)心包摩擦感无有

Percussion:relativecardiacoutline:normalshrinkextant(rightleft)

叩诊相对浊音界正常缩小扩大(右左)

Ausculation:heartratebpm/minrhythm(regularirregular

听诊心率次/分心律(齐不齐)

absolutlyirrgelar)heartsound:S1normalincreaseddecreased

绝对不齐心音S1正常增强减弱

splitS2normalincreaseddecreasedsplit

分裂S2正常增强减弱分裂

S3NYS4NYA2P2

S3无有S4无有A2P2

ExtraheartsoundNgallop(diastolicpresystoticsummalion

额外心音无奔马律(舒张期收缩前期重叠

gallop)openingsnapothersmurmurs:NY(degreeconduction)

开瓣音其他杂音无有(图示并描述传导)

PericardialfrictionrubsNY

心包摩擦音无有

Peripheralvessals:normalpistalshotofbigarteries

周围血管无异常血管征大血管枪击音

Duroziez’ssignwaterhammerpulsecapillarypulsation

二重杂音水冲脉毛细血管搏动

pulsedeficitparadoxicalpulsepulsusalternansother

脉搏短绌奇脉交替脉其他

Abdoman

腹部

Inspection:shapenormaldistentionfrogabdomen(sizecm)

视诊外形正常膨隆蛙腹(腹围厘米)

scaphoidapicalabdomengastralpatternintestinalpattern

舟腹尖腹胃型肠型

peristalsisabdominalrespiration:existancedisappearumbilicus:

蠕动波腹式呼吸存在消失脐

normalprotrudingexcretionsothers:NY(venousdistentionof

正常凸出分泌物其他异常无有(腹壁静脉曲张

abdomanpurplestriaesurgicalscarshernia)

条纹手术疤痕疝)

Palpation:softmuscletensionpositiontendernessNY

触诊柔软腹肌紧张部位压痛无有reboundtendernessNYfluidthtillNYsuccussionsplashNY

反跳痛无有液波震颤无有振水音无有

MassNY(positionsize)discriptionoffeatureliver:can’tbe腹部包块无有(部位大小)特征描述肝未触及

touchedcanbetouched:subcostalcmunderxipfoidprocess

可触及肋下厘米剑突下

discriptionoffeaturegallbladder:can’tbetouchedcanbetouched

特征描述胆囊未触及可触及

sizecmtendernessNYMurphy’ssignspleen:can’tbe大小厘米压痛无有Murphy征脾未触及

touchedcanbetoucheddistancefromcostalmargincm

可触及肋下厘米

Kideny:can’tbetouchedcanbetouchedsizeconsistency

肾未触及可触及大小硬度

tendernessmobilitytendernessofureters:NY(position)

压痛移动度输尿管压痛点无有(部位)

percussion:bordersofliverdull(existanceshrinkobliteration)

叩诊肝浊音界(存在缩小消失)

Upperbordersofliveronrightmidclavicularlineintercostalspace肝上界位于右锁骨中线肋间

shiftingdullnessNYtendernessinrenalregionNY(rightleft)

移动性浊音无有肾区叩痛无有(右左)

ausculation:borhorygmusnormalincreaseddecreased

听诊肠鸣音正常增强减弱

disappeargurglingNYvessalbruitsNY(position)

消失气过水声无有血管杂音无有(部位)

Genitalia:notexaminednormalabnormalRectumandAnus:

生殖器未查正常异常肛门直肠

notexaminednormalabnormal

未查正常异常

SpineandExtremities

脊柱四肢

Spine:normaldeformities(lateralanteriorposteriorprotruding)

脊柱正常畸形(侧前后凸)

Spinousprocess:tendernesspainwhilepercussed(position)

棘突压痛叩痛(部位)

Mobility:normalrestrictedextremeties:normalabnormal

移动度正常受限四肢正常异常

deformityswellingofjointsjointsstiffness

畸形关节红肿关节强直

tendernessofmusclesatrophyofmuscles

肌肉压痛肌肉萎缩

Venousdistentionoflowerlimbs(positionandfeature)acropachy

下肢静脉曲张(部位及特征)杵状指

NervusSystem

神经系统

Abdominalwallreflex(normal)muscletone(normal)

腹壁反射(正常)肌张力(正常)

Myodynamia(degree)paralysisoflimbsNY(leftright

肌力(级)肢体瘫痪无有(左右

upperlower)bicepsreflexleft(normal)right(normal)

上下)肱二头肌反射左(正常)右(正常)kneejerkleft(normal)right(normal)achillesjerkleft

膝健反射左(正常)右(正常)跟腱反射左

(normal)right(normal)

正常右(正常)

Hoffmann’sdignleft(+)(-)right(+)(-)

Hoffmann征左(+)(-)右(+)(-)

Babinski’ssignleft(+)(-)right(+)(-)

Babinski左(+)(-)右(+)(-)

Kernig’ssignleft(+)(-)right(+)(-)others

Kernig征左(+)(-)右(+)(-)其他

Laboratoryfindings

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