住院病历中英文对照.docx

1.POMR (Problem-Oriented Medical Records)表格式住院病历2.Biographical data: 一般项目：3.Name Age Sex Marital status Nativity Race姓名 年龄 性别 婚否 籍贯 民族4.Occupation Date of admission Informant History职业 入院日期 病史叙述者 病史5.Chief complaint 主诉6.History of present illness 现病史Past history 既往史：7.Previous health status: well ordinary bad Infectious diseases平素健康状况： 良好 一般 较差 传染病史8.Immunizations Allergies: N Y clinical manifestation预防接种史 过敏史 无 有 临床表现9.allergen: Trauma: Surgery:过敏原 外伤史 手术史10.Review of systems: (Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy)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)11.Respiratory system: 呼吸系统12.Sore throat chronic cough sputum hemoptysis wheezing 咽痛 慢性咳嗽 咳痰 咯血 哮喘13.dyspnea chest pain呼吸困难 胸痛14.cadiovascular system:循环系统15.Palpitation dyspnea on exertion hemoptysis syncope心悸 活动后气促 咯血 晕厥 16.edema of lower limbs precordial pain hypertention3 m4 G: a6 ] h下肢水肿 心前区疼痛 高血压Digestive system:消化系统Anorexia sour regurgitation belching nausea vomitting; L. N) o# e w! A$ H* W食欲减退 反酸 嗳气 恶心 呕吐 abdominal distention abdominal pain constipation diarrhea 8 G1 d; G# P$ `( ]腹胀 腹痛 便秘 腹泻8 t) }/ q7 i' v# ]6 Vhematemesis melena hematochezia jaundice% c2 h V4 r7 {- S皮下出血 骨痛 鼻衄 0 b* ?5 ] ~ R* a# b( A“ g e* HMetabolic and endocrine system:代谢及内分泌系统Excessive appetite anorexia sweats cold intolerance 食欲亢进 食欲减退 多汗 畏寒“ f8 X: \! j |4 A r6 zpolydipsia tremor hands change of character obvious obesity 0 [: z) L! A Y, Z# ]2 fMusculoskeletal system - \+ }/ L6 H8 e8 A9 H; {# G肌肉骨骼系统2 G1 W5 f1 z BFloating arthralgia arthraliga swelling of joints 游走性关节痛 关节痛 关节红肿deformiteies of jionts myalgia atrophy of muscle ! f7 T4 \% p; e. ^; n关节变形 肌肉痛 肌肉萎缩 Nervous system0 J8 Y( x1 f, O1 u/ t- o9 ^神经系统: t0 N! C' {/ ?% w, W# b“ jDizziness headache vertigo syncope degeneration of memory 头昏 头痛 眩晕 晕厥 记忆力减退visual disturbance insomnia disturbance of consciousness # I4 o+ M6 U# l视力障碍 失眠 意识障碍4 V6 b- W* m2 L; y% ktremor spasm paralysis paresthesia颤动 抽搐 瘫痪 感觉异常 Personal history:5 X- f( t5 O) p8 H% ]个人史Birthplace Occupation sexual history smoking N Y 4 ]% S6 l7 e; O* u; F+ g) c3 B出生地 职业 冶游史 吸烟 无 有about years average pieces per day ceased for years ) z' c! [2 C9 h( \0 c约 年 平均 支/日 戒烟 年* b0 V6 ]/ t- z L% a5 Ialcohol intake N occasional frequent about years - P% x M4 u w1 S# X1 c. x嗜酒 无 偶有 经常 约为 年1 U# ^( f+ i; Q7 laverage ml per day others 平均 ml/日 其他 ) h- Y4 x. U( DMarital history:婚姻史：, {0 t( o, A, ^8 g3 q+ lMarrying age companion’s state of health: x5 z. E8 i/ X) W5 M! ?- Q* ~/ t结婚年龄 配偶健康状况6 d9 R1 x5 p9 d# |1 |Menorrhea and Childbearing:7 ?) X E初潮 每次持续时间 末次月经时间(age of menopause)绝经年龄. G$ \0 @5 x; I+ ?“ tAmount of flow: little normal large menstrual pain: N Y 经量 少 正常 多 痛经 无 有cycle: regular irregular pregnancy times natural labor/ ?1 F% D1 t8 u9 t( S7 J+ q“ s) q经期 规则 不规则 妊娠 次 顺产times abortions times premature delivery times $ b0 E4 k7 B, u胎 流产 胎 早产 胎' Z' _/ h. _* K8 t) w B! D1 Hstillbirths times difficult labor and its condition6 p0 y, q“ B6 z, W9 J死产 胎 难产及病情% w' U9 {: f) V% ~Familly history (pay attention to the congenital diseases and ' N5 x# u% Y- F _4 ?communicable diseases and communicable dieases related to the paitent! N* F; u- `3 c! }/ c( T2 w家族史 （注意与患者现病有关的遗传病和传染性疾病）3 L2 p4 s0 Z- _Father: still alive illness died cause of deaths mother: 父：健在 患病 已故 死因 母 still alive illness died cause of death siblings: others:健在 患病 已故 死因 兄弟姐妹 子女其他8 [+ E( v2 e) e“ b4 A# ~Physical examination 体格检查' c/ _( P5 `0 E+ F$ B5 O+ pVital signs 生命体征: ' | P( f“ M0 W8 JTemperature 体温4 z+ p( |/ \# Y' @“ z, g3 D- b9 [pulse 脉搏 /min 次/分 respiration 呼吸 /min 次/分 / X# @+ O( V. |; t0 y. q2 [B.P 血压 mmHg% B2 K) S+ W8 I! l( L6 XGeneral Appearance 一般状况:Development 发育: ortho-sthenic type 正常 * Z3 h- t. N: ]+ A$ v0 \ _' T“ l# pnormal 无病容 acute 急性 “ T, P9 u, Z: w6 ~chronic 慢性病容 3 D2 @9 U; p/ h! t! N) Y$ Xothers 其他; i' P5 M9 L7 P; yExpression 表情: natural 自知 % A0 j: p. n8 Y/ Z$ x1 g8 L) }painful 痛苦 ' H+ M3 K! p) q“ ^0 _anxious 忧虑 . w T# n, I4 O2 F3 Y* G$ Gdreadful 恐惧 ) ?' P) K2 G“ k# H/ b- i9 |$ Windifferent 淡漠0 L' f3 h2 `) A6 e B% n) A [“ \9 k) `8 I步态 正常 不正常6 d: I5 w; K6 c8 m7 IConciousness: aware somnolence confusion stupor coma a- u( f L* g! ]- L' e, v9 J, u神志 清楚 嗜睡 模糊 昏睡 昏迷 delirium coppperatio; well badly2 A5 R8 S L0 c谵妄 配合检查 合作 不合作. F; M4 ]* z“ I, `2 H: D+ W( YMucocutaneous color: normal red pale cyaosis stainted “ d o# D+ D) _, t5 M. T I% r. z皮肤粘膜 色泽 无病容 潮红 苍白 紫绀 yellow pigmentation lesions:N Y (type and distribution); J+ n3 c; k, q ~; `7 }3 LSuperficial lymph nodes: non-swelling swelling(position and characteristics)“ L, R“ z! P. y* p0 i# F9 m全身淋巴结肿大 无肿大 肿大（部位及特征）3 Q/ M* U' k1 H! z! |6 HHead : cranium : size : normal large small deformity: G% A( c- L$ F: x% \+ S Znormal hyperemia edema hemrrhage正常 充血 水肿 出血 2 n u. |3 Y+ q8 e0 Ieye ball: normal proptosis depression tremor - e8 o+ {# m, G% ^* Z, z; p“ v眼球 正常 突出 凹陷 震颤 motion dysfunction(left right)运动障碍Sclera :normal yellow cornea : normal abnormal ( left right )巩。