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住院病歷的英漢對(duì)照
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Translation 發(fā)表于 2015/9/17 12:55:15

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住院病歷的英漢對(duì)照

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POMR (Problem-Oriented Medical Records)表格式住院病歷

Biographical data:

一般項(xiàng)目：

Name Age Sex Marital status Nativity Race

姓名年齡性別婚否籍貫民族

Occupation Date of admission Informant History

職業(yè) 入院日期病史敘述者病史

Chief complaint

主訴

History of present illness

現(xiàn)病史

Past history

既往史：

Previous health status: well ordinary bad Infectious diseases

平素健康狀況：良好一般較差傳染病史

Immunizations Allergies: N Y clinical manifestation

預(yù)防接種史過敏史無有臨床表現(xiàn)

allergen: Trauma: Surgery:

過敏原外傷史手術(shù)史

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)

系統(tǒng)回顧：(有打√無打×陽性病史應(yīng)在下面空間內(nèi)填寫發(fā)病時(shí)間及扼要診療經(jīng)過)

Respiratory system:

呼吸系統(tǒng)

Sore throat chronic cough sputum hemoptysis wheezing

咽痛慢性咳嗽咳痰咯血哮喘

dyspnea chest pain

呼吸困難胸痛

cadiovascular system:

循環(huán)系統(tǒng)

Palpitation dyspnea on exertion hemoptysis syncope

心悸活動(dòng)后氣促咯血暈厥

edema of lower limbs precordial pain hypertention

下肢水腫心前區(qū)疼痛高血壓

Digestive system:

消化系統(tǒng)

Anorexia sour regurgitation belching nausea vomitting

食欲減退反酸噯氣惡心嘔吐

abdominal distention abdominal pain constipation diarrhea

腹脹腹痛便秘腹瀉

hematemesis melena hematochezia jaundice

嘔血黑便便血黃疸

Urinary system:

泌尿系統(tǒng)

Lumbago frequent micturition urgent micturition urodynia

腰痛尿頻尿急尿痛

dysuria hematuria nocturia polyuria oliguria facial edema

排尿困難血尿夜尿多尿少尿面部水腫

Hematopoietic system

造血系統(tǒng)

Fatigue dizziness blurred vision gingival bleedig

乏力頭昏牙齦出血

subcutaneous hemorrhage ostealgia epistaxis

皮下出血骨痛鼻衄

Metabolic and endocrine system:

代謝及內(nèi)分泌系統(tǒng)

Excessive appetite anorexia sweats cold intolerance

食欲亢進(jìn) 食欲減退多汗畏寒

polydipsia tremor hands change of character obvious obesity

多飲雙手震顫性格改變顯著肥胖

emaciation hirsutism hair losing pigmentation

消瘦多毛毛發(fā)脫落色素沉著

chang of sexual function amenorrhea

性功能改變閉經(jīng)

Musculoskeletal system

肌肉骨骼系統(tǒng)

Floating arthralgia arthraliga swelling of joints

游走性關(guān)節(jié)痛關(guān)節(jié)痛關(guān)節(jié)紅腫

deformiteies of jionts myalgia atrophy of muscle

關(guān)節(jié)變形肌肉痛肌肉萎縮

Nervous system

神經(jīng)系統(tǒng)

Dizziness headache vertigo syncope degeneration of memory

頭昏頭痛眩暈暈厥記憶力減退

visual disturbance insomnia disturbance of consciousness

視力障礙失眠意識(shí)障礙

tremor spasm paralysis paresthesia

顫動(dòng) 抽搐癱瘓感覺異常

Personal history:

個(gè)人史

Birthplace Occupation sexual history smoking N Y

出生地職業(yè) 冶游史吸煙無有

about years average pieces per day ceased for years

約年平均支/日戒煙年

alcohol intake N occasional frequent about years

嗜酒無偶有經(jīng)常約為年

average ml per day others

平均 ml/日其他

Marital history:

婚姻史：

Marrying age companion’s state of health

結(jié)婚年齡配偶健康狀況

Menorrhea and Childbearing:

月經(jīng)及生育史

Menarche age cycle lasting for days date of last period

初潮每次持續(xù)時(shí)間末次月經(jīng)時(shí)間

(age of menopause)

絕經(jīng)年齡

Amount of flow: little normal large menstrual pain: N Y

經(jīng)量少正常多痛經(jīng) 無有

cycle: regular irregular pregnancy times natural labor

經(jīng)期規(guī)則不規(guī)則妊娠次順產(chǎn)

times abortions times premature delivery times

胎流產(chǎn) 胎早產(chǎn) 胎

stillbirths times difficult labor and its condition

死產(chǎn) 胎難產(chǎn)及病情

Familly history (pay attention to the congenital diseases and

communicable diseases and communicable dieases related to the paitent

家族史（注意與患者現(xiàn)病有關(guān)的遺傳病和傳染性疾?。?/font>

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

Physical examination體格檢查

Vital signs生命體征:

Temperature體溫

pulse脈搏 /min次/分

respiration呼吸 /min次/分

B.P血壓 mmHg

General Appearance一般狀況:

Development發(fā)育:

ortho-sthenic type正常

asthenic type不良

sthenic type超常

nutrition營(yíng)養(yǎng):

well良好

fairly中等

poor不良

cachexia惡病質(zhì)

Facial features面容:

normal無病容

acute急性

chronic慢性病容

others其他

Expression表情:

natural自知

painful痛苦

anxious憂慮

dreadful恐懼

indifferent淡漠

Position: active semi-recumbent others

體位：自主半臥位其他

Gait: normal abnormal

步態(tài) 正常不正常

Conciousness: aware somnolence confusion stupor coma

神志清楚嗜睡模糊昏睡昏迷

delirium coppperatio; well badly

譫妄配合檢查合作不合作

Mucocutaneous color: normal red pale cyaosis stainted

皮膚粘膜色澤無病容潮紅蒼白紫紺

yellow pigmentation lesions:N Y (type and distribution)

黃染色素沉著皮疹無有（類型及分布）

Subcutaneous hemorrhange: N Y(type and distribution)

皮下出血無有（類型及分布）

Hair: normal reduced edema: N Y(position and degree)

頭發(fā)分布正常減退水腫無有（部位及程度）

Hepatic palm: N Y spider angionma:N Y（position numbers ） others:

肝掌無有蜘蛛痣無有(部位數(shù)目) 其他

Lymphnodes:

淋巴結(jié)

Superficial lymph nodes: non-swelling swelling(position and characteristics)

全身淋巴結(jié)腫大無腫大腫大（部位及特征）

Head : cranium : size : normal large small deformity:

頭部頭顱大小正常大小畸形

N Y(coxycephaly squared skull deforming skull)

無有（尖顱方顱變形顱）

Others: tenderness mass sunk (position)

其他異常：壓痛包塊凹陷（部位）

Eyes eyelid: normal edema ptosis trichiasis conjunctive :

眼瞼正常水腫下垂倒睫結(jié)膜

normal hyperemia edema hemrrhage

正常充血水腫出血

eye ball: normal proptosis depression tremor

眼球正常突出凹陷震顫

motion dysfunction(left right)

運(yùn)動(dòng)障礙

Sclera :normal yellow cornea : normal abnormal ( left right )

鞏膜無黃染有黃染角膜正常異常（左右）

Pupils: equal roundness same size unequal left cm

瞳孔等圓等大不等左 cm

reaction to light: normal delay (left right) disappear (left right) 對(duì)光反射正常遲鈍（左右）消失（左右）

Others:

其他

Ears: auricle :normal deformity fistula others (left right )

耳耳廓正常畸形瘺管其他（左右）

excretions of external auditory canal: N Y (left right feature)

外耳道分泌物無有（左右性質(zhì)）

Tenderness of mastoid : N Y audation dysfunction: N Y (left right)

乳突壓痛無有聽力粗試障礙無有（左右）

Nose: shape : normal: abnormal ( ) other abnormalities:N Y

鼻外形正常異常（）其他異常無有

Nosalala flap obsruction excretions nasal sinus tenderness:

鼻翼扇動(dòng) 鼻塞分泌物鼻旁竇壓痛

N Y (position )

無有（部位）

Mouth lips :red syanosis pale herpes fissure mucosa :normal

口唇紅潤(rùn) 發(fā)紺蒼白皰疹皸裂粘膜正常

abnormal ( pale petechia)

異常（蒼白出血點(diǎn)）

Opening of parotid gland duct: normal abnormal (swelling

腮腺導(dǎo)管開口正常異常（腫脹

suppurative excretions)

膿性分泌物）

Tongue:normal abnormal (coverings tremor leaning to left or right)

舌正常異常（舌苔伸舌震顫向左、向右偏斜）

Gums: normal swelling pus overflow hemorrhage pigments

牙齦正常腫脹溢膿出血色素沉著

lead line tooth:regular edentulous carious teeth

鉛線牙列齊缺牙—|— 齲齒—|—

Tonsils: pharynx: voice: normal hoarse

扁桃體咽聲音正常嘶啞

Neck:resistence:N Y carotid artery pulsation: normal increased

頸部抵抗感無有頸動(dòng)脈搏動(dòng) 正常增強(qiáng)

decreased (left right) jugular vein:normal distention

減弱（左右）頸靜脈正常充盈

high distention trachea:middle deviation to (left right)

怒張氣管正中偏移（向左向右）

Hepatojugular reflux:(-) (+) thyroid: normal swelling degree

肝頸靜脈回流征：（-）（+）甲狀腺正常腫大度

Symmetry 對(duì)稱

Dominance in one side: spreading nodular:soft hard others :N Y

側(cè)為主彌漫性結(jié)節(jié)性質(zhì)軟質(zhì)硬其他無有

(tenderness tremor bruits)

（壓痛震顫血管雜音）

Chest topography:normal barrel chest pigeon chest funnel chest

胸部胸廓正常桶狀胸雞胸漏斗胸

flat chest bulging or retraction (left right )

扁平胸膨隆或凹陷（左右）

bulging in the precordial region tenderness of sternum

心前區(qū)膨隆胸骨壓痛

Breast: normal symmetrical abnormal : left right(gynecomastia

乳房正常對(duì)稱異常左右（男乳女化

mass tenderness excretions of nipples)

包塊壓痛乳頭分泌物）

Lung

肺

Inspection : movement of respiration : normal abnormal : left

視診呼吸運(yùn)動(dòng) 正常異常左

right( increased decreased)

右（增強(qiáng) 減弱）

Intercostal space :normal wide narrow(position)

肋間隙正常增寬變窄（部位）

Palpation : vocal fremitus:normal abnormal :left right (increased

觸診：語顫正常異常左右（增強(qiáng)

decreased ) pluernal friction rubs: N Y（position）

減弱胸膜摩擦感：無有（部位）

Subcutaneous crepitus: N Y(posotion) percussion: resonance

皮下捻發(fā)感無有（部位）叩診正常清音

abnormal dullness flatness hyperresonance tympany

異常叩診音濁音實(shí)音過清音鼓音

Lower borders:scapular line: right intercostal space, left

肺下界肩胛線右肋間左

intercostal space Range of mobility: right cm , left cm

肋間移動(dòng)度右 cm，左 cm

Dusculation: breath regular irregular

聽診呼吸規(guī)整不規(guī)整

Breath sound: normal abnormal( feature, position )

呼吸音正常異常（性質(zhì)，部位描寫）

Rale: N Y ：ronchi: sonorous sibilant

啰音：無有：干性鼾音哨笛音

Moist rales: coarse medium fine rales crepitus

濕性大中小水泡音捻發(fā)音

Vocal conduction: normal abnormal: reduced increased(position)

語音傳導(dǎo) 正常異常減弱增強(qiáng) （部位）

Plueral friction rubs: N Y (position)

胸膜摩擦音無有（部位）

Heart 心

Inspection:bulging in precordial region : N Y apex impulse:

視診心前區(qū)隆起無有心尖搏動(dòng)

normal unseen increased diffusing position: normal

正常未見增強(qiáng) 彌散心尖搏動(dòng)位置正常

deviation ( the distance from midclavicular line cm)

移動(dòng) （距左鎖骨中線內(nèi)外厘米）

Other precordial pulsations: N Y (position)

其他部位搏動(dòng) 無有（部位）

Palpation:apex impulse:normal increased thrust unclear

觸診心尖搏動(dòng) 正常增強(qiáng) 抬舉感觸不清

thrills :N Y (position period) percardial friction rubs:N Y

震顫無有（部位時(shí)期）心包摩擦感無有

Percussion:relative cardiac outline: normal shrink extant (right left )

叩診相對(duì)濁音界正常縮小擴(kuò)大（右左）

Ausculation: heart rate bpm/min rhythm(regular irregular

聽診心率次/分心律（齊不齊）

absolutly irrgelar) heart sound:S1 normal increased decreased

絕對(duì)不齊心音 S1 正常增強(qiáng) 減弱

split S2 normal increased decreased split

分裂 S2 正常增強(qiáng) 減弱分裂

S3 N Y S4 N Y A2 P2

S3 無有 S4 無有 A2 P2

Extra heart sound N gallop (diastolic presystotic summalion

額外心音無奔馬律（舒張期收縮前期重疊

gallop) opening snap others murmurs: N Y (degree conduction)

開瓣音其他雜音無有（圖示并描述傳導(dǎo)）

Pericardial friction rubs N Y

心包摩擦音無有

Peripheral vessals: normal pistal shot of big arteries

周圍血管無異常血管征大血管槍擊音

Duroziez’s sign water hammer pulse capillary pulsation

二重雜音水沖脈毛細(xì)血管搏動(dòng)

pulse deficit paradoxical pulse pulsus alternans other

脈搏短絀奇脈交替脈其他

Abdoman

腹部

Inspection: shape normal distention frog abdomen( size cm)

視診外形正常膨隆蛙腹（腹圍厘米）

scaphoid apical abdomen gastral pattern intestinal pattern

舟腹尖腹胃型腸型

peristalsis abdominal respiration:existance disappear umbilicus:

蠕動(dòng)波腹式呼吸存在消失臍

normal protruding excretions others: N Y(venous distention of

正常凸出分泌物其他異常無有（腹壁靜脈曲張

abdoman purple striae surgical scars hernia)

條紋手術(shù)疤痕疝）

Palpation: soft muscle tension position tenderness N Y

觸診柔軟腹肌緊張部位壓痛無有rebound tenderness N Y fluidthtill N Y succussions plash N Y

反跳痛無有液波震顫無有振水音無有

Mass N Y(position size) discription of feature liver:can’t be 腹部包塊無有（部位大?。?特征描述肝未觸及

touched can be touched :subcostal cm under xipfoid process

可觸及肋下厘米劍突下

discription of feature gallbladder: can’t be touched can be touched

特征描述膽囊未觸及可觸及

size cm tenderness N Y Murphy’s sign spleen: can’t be 大小厘米壓痛無有 Murphy征脾未觸及

touched can be touched distance from costal margin cm

可觸及肋下厘米

Kideny:can’t be touched can be touched size consistency

腎未觸及可觸及大小硬度

tenderness mobility tenderness of ureters: N Y (position)

壓痛移動(dòng)度輸尿管壓痛點(diǎn) 無有（部位）

percussion: borders of liver dull(existance shrink obliteration )

叩診肝濁音界（存在縮小消失）

Upper borders of liver on right midclavicular line intercostal space 肝上界位于右鎖骨中線肋間

shifting dullness N Y tenderness in renal region N Y (right left )

移動(dòng)性濁音無有腎區(qū)叩痛無有（右左）

ausculation : borhorygmus normal increased decreased

聽診腸鳴音正常增強(qiáng) 減弱

disappear gurgling N Y vessal bruits N Y (position)

消失氣過水聲無有血管雜音無有（部位）

Genitalia :not examined normal abnormal Rectum and Anus :

生殖器未查正常異常肛門直腸

not examined normal abnormal

未查正常異常

Spine and Extremities

脊柱四肢

Spine : normal deformities (lateral anterior posterior protruding)

脊柱正常畸形（側(cè) 前后凸）

Spinous process : tenderness pain while percussed ( position )

棘突壓痛叩痛（部位）

Mobility : normal restricted extremeties: normal abnormal

移動(dòng)度正常受限四肢正常異常

deformity swelling of joints joints stiffness

畸形關(guān)節(jié)紅腫關(guān)節(jié)強(qiáng)直

tenderness of muscles atrophy of muscles

肌肉壓痛肌肉萎縮

Venous distention of lower limbs (position and feature ) acropachy

下肢靜脈曲張（部位及特征）杵狀指

Nervus System

神經(jīng)系統(tǒng)

Abdominal wall reflex ( normal ) muscle tone ( normal )

腹壁反射（正常）肌張力（正常）

Myodynamia ( degree ) paralysis of limbs N Y (left right

肌力（級(jí) ）肢體癱瘓無有（左右

upper lower) biceps reflex left (normal) right (normal)

上下）肱二頭肌反射左（正常）右（正常） knee jerk left (normal) right( normal) achilles jerk left

膝健反射左（正常）右（正常）跟腱反射左

(normal) right ( normal )

正常右（正常）

Hoffmann’s dign left (+)(-) right(+)(-)

Hoffmann征左（+）(-) 右（+）（-）

Babinski’s sign left(+)（-） right(+)(-)

Babinski 左（+）（-）右（+）（-）

Kernig’s sign left(+)（-）right(+)(-) others

Kernig征左（+）（-）右（+）（-）其他

Laboratory findings

實(shí)驗(yàn)室及器械檢查結(jié)果

（The important laboratory examination .X-ray . ECG and other result areincluded） (重要的化驗(yàn)、X線、心電圖及其他有關(guān)化驗(yàn)) Nunber of X-ray

X線片號(hào)

Abstract

病歷摘要

Diagnosis(impressions)

入院診斷

Recorder

病史記錄者

Examiner

并使審閱者

Date of record

記錄日期

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