住院病历中英文对照

1.POMR (Problem-Oriented Medical Records)表格式住院病历

2.Biographical data:一般项目：

https://www.360docs.net/doc/2b14648297.html, 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 V hematemesis melena hematochezia

jaundice% c2 h& ^) w% r/ G% s# i9 c- h

呕血黑便便血黄疸

Urinary system:

泌尿系统

Lumbago frequent micturition urgent micturition urodynia

腰痛尿频尿急尿痛7 D) {2 U/ K# ?5 L9 L V9 G dysuria hematuria nocturia polyuria oliguria facial edema

排尿困难血尿夜尿多尿少尿面部水肿Hematopoietic system

造血系统

Fatigue dizziness blurred vision gingival bleedig

乏力头昏牙龈出血" j9 w, N. P5 j m! C subcutaneous hemorrhage ostealgia

epistaxis ' z$ {% i; V4 r7 {- S

皮下出血骨痛鼻衄0 b* ?5 ] ~ R* a# b( A" g e* H

Metabolic 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 z

polydipsia tremor hands change of character obvious obesity 0 [: z) L! A& M/ {+ y$ l 多饮双手震颤性格改变显著肥胖* D* N. t& S& i# | p- _& ]

- E. ^% k" v5 ]6 A* g

emaciation hirsutism hair losing pigmentation

消瘦多毛毛发脱落色素沉着: N d4 x! B5 R chang of sexual function amenorrhea

性功能改变闭经. T' J. A; Y, Z# ]2 f Musculoskeletal system - \+ }/ L6 H8 e8 A9 H; {# G

肌肉骨骼系统2 G1 W5 f1 z B

Floating 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" j

Dizziness 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% k tremor 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 I

alcohol 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 l average ml per day others

平均ml/日其他) h- Y4 x. U( D

Marital history:

婚姻史：, {0 t( o, A, ^8 g3 q+ l

Marrying 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& }9 g+ D 月经及生育史( a0 C* S& i9 z5 l* A2 Y- @Menarche age cycle lasting for days date of last period ' p! q' T+ S+ s, t: D; 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+ ?" t

Amount 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 H stillbirths 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& O5 Q g; _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+ p

Vital signs生命体征: ' | P( f" M0 W8 J Temperature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 X General Appearance一般状况: Development发育:

ortho-sthenic type正常* Z3 h- t. N: ]+ A$ v0 \& @! s

asthenic type不良

sthenic type超常

nutrition营养: . |$ W2 G* Z" I0 I- c$ N- n+ }$ T9 V# s

well良好: Q/ b3 ]* R9 }2 L& T. \

fairly中等7 A( k0 d2 r( ^& Z( l

poor不良0 O6 c8 T9 a6 S" M

cachexia恶病质6 e D7 Z& U- A. m9 E! R

Facial features面容: , N; _' T" l# p

normal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$ X others其他; i' P5 M9 L7 P; y

Expression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$ G dreadful恐惧) ?' P) K2 G" k# H/ b- i9 |$ W indifferent淡漠0 L' f3 h2 `) A6 e B% n

) A& k R6 Y y/ r

Position: active semi-recumbent others

体位：自主半卧位其他

Gait: normal abnormal & M; [" \9 k) `8 I

步态正常不正常6 d: I5 w; K6 c8 m7 I Conciousness: 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& y; L0 c

谵妄配合检查合作不合作. F; M4 ]* z" I, `2 H: D+ W( Y

Mucocutaneous 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& E& n8 ?) E

黄染色素沉着皮疹无有（类型及分布）. S$ t, a P. N- g7 Z* B1 [7 n

Subcutaneous hemorrhange: N Y(type and distribution) 6 X+ Q# t1 V% u8 |* j

皮下出血无有（类型及分布）

Hair: normal reduced edema: N Y(position and degree), ?0 k% H, o* k9 K

头发分布正常减退水肿无有（部位及程度）0 v0 E3 h+ R e* X t& k0 u

Hepatic palm: N Y spider angionma:N Y （position numbers ）others:% }2 B3 N d+ ]- h% C

肝掌无有蜘蛛痣无有(部位数目) 其他

Lymphnodes:

淋巴结8 ?* k' ^- @; ~; `7 }3 L

Superficial 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 H

Head : cranium : size : normal large small deformity: & ~/ R' k4 G" d y6 F

头部头颅大小正常大小畸形

N Y(coxycephaly squared skull deforming skull)

无有（尖颅方颅变形颅）/ `6 w/ i& t4 [0 b8 w% N2 V

) C8 N: J$ V6 e4 H# J/ C. R

Others: tenderness mass sunk (position) 其他异常：压痛包块凹陷（部位）

Eyes eyelid: normal edema ptosis trichiasis conjunctive :

眼睑正常水肿下垂倒睫结膜; G% A( c- L$ F: x% \+ S Z

normal hyperemia edema hemrrhage

正常充血水肿出血2 n u. |3 Y+ q8 e0 I

eye 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 )

巩膜无黄染有黄染角膜正常异常（左右）5 W. R' Z; G1 ?7 E' t1 r2 ]

Pupils: equal roundness same size unequal left cm

瞳孔等圆等大不等左cm

reaction to light: normal delay (left right) disappear (left right) 对光反射正常迟钝

（左右）消失（左右）+ q: P/ Z* j. b1 \ Others:+ Q6 P: J7 y2 `, L- E) d

其他

Ears: auricle :normal deformity fistula others (left right )) W/ o4 I2 G- n- w9 u

耳耳廓正常畸形瘘管其他（左右）' y4 _3 U6 s+ ~3 r

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

外耳道分泌物无有（左右性质）" s7 Q& F3 F9 F4 u

Tenderness of mastoid : N Y audation dysfunction: N Y (left right)* d# J+ p( h7 l; h/ b0 n3 B

乳突压痛无有听力粗试障碍无有（左右）; O* @3 E: A3 C6 O2 S' U

Nose: shape : normal: abnormal ( ) other abnormalities:N Y " [+ D9 q% E7 o$ [1 _. u6 |

鼻外形正常异常（）其他异常无有Nosalala flap obsruction excretions nasal sinus tenderness: ( y5 l v- ^$ q# I5 O

鼻翼扇动鼻塞分泌物鼻旁窦压痛! t% }: g4 Z ? R$ w/ K% q; O, {

N Y (position )

无有（部位）

Mouth lips :red syanosis pale herpes fissure mucosa :normal

口唇红润发绀苍白疱疹皲裂粘膜正常) ]" J+ D2 r4 A

abnormal ( pale petechia)

异常（苍白出血点） `. A% }" a1 r( H. X, s3 [ Opening of parotid gland duct: normal abnormal (swelling

腮腺导管开口正常异常（肿胀9 W) J* s- G7 R

suppurative excretions)

脓性分泌物）

Tongue:normal abnormal (coverings tremor leaning to left or right)) i2 S9 v, a( l7 Q" s

舌正常异常（舌苔伸舌震颤向左、向右偏斜）

Gums: normal swelling pus overflow hemorrhage pigments " b6 e. i4 G7 u$ y, s

牙龈正常肿胀溢脓出血色素沉着lead line tooth:regular edentulous carious teeth

铅线牙列齐缺牙—|—龋齿—|—) @/ `+ l0 q' ]% o! n6 R

Tonsils: pharynx: voice: normal hoarse

扁桃体咽声音正常嘶哑2 T/ [5 w/ ?5 M: T2 X$ M; y: e

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

颈部抵抗感无有颈动脉搏动正常增强

decreased (left right) jugular vein:normal distention

减弱（左右）颈静脉正常充盈high distention trachea:middle deviation to (left right)4 A- o( z0 ]4 v1 ]

怒张气管正中偏移（向左向右）9 L" u$ S* n; g

Hepatojugular reflux-) (+) thyroid:

normal swelling degree

肝颈静脉回流征：（-）（+）甲状腺正常肿大度

Symmetry 对称

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

侧为主弥漫性结节性质软质硬其他无有) J% t9 _6 m% L# G5 t) s

(tenderness tremor bruits)

（压痛震颤血管杂音）

Chest topography:normal barrel chest pigeon chest funnel chest

胸部胸廓正常桶状胸鸡胸漏斗胸; t3 d" t& E+ i" U% Q" b

flat chest bulging or retraction (left right ) 扁平胸膨隆或凹陷（左右）7 L* H# A2 k5 i"

a j- X7 j

u8 _; x9 q# {0 S* E: Y: y. U

bulging in the precordial region tenderness of sternum

心前区膨隆胸骨压痛" y( Z- M7 L0 w# V9 j Breast: normal symmetrical abnormal : left

right(gynecomastia # v7 a, j, s& ^0 x* c- }( {

乳房正常对称异常左右（男乳女化mass tenderness excretions of nipples)1 V' k6 p0 {& l9 A) z0 [

包块压痛乳头分泌物） J+ T) x3 ~* ^% U

" [0 h% y& }( C1 @, c, A

Recorder

病史记录者

Examiner

并使审阅者

Date of record

记录日期3

A/ r. Z+ n4 S5 B2 {3 A

Lung

肺

Inspection : movement of respiration : normal abnormal : left ) P3 }5 |5 T6 w

视诊呼吸运动正常异常左1 r6 [) C3 c; A+ L A( Y1 R

right( increased decreased)2 I7 |9 A; c5 x& K0 L0 L" \( m

右（增强减弱）& R" S1 D3 L9 {/ L( I Intercostal space :normal wide narrow(position)

肋间隙正常增宽变窄（部位）. ~$ r- O8 l0 ]' J/ `5 X4 m

Palpation : vocal fremitus:normal abnormal :left right (increased 2 n; o1 r$ Q/ ?1 Q% [& V

触诊：语颤正常异常左右（增强decreased ) pluernal friction rubs: N Y （position）7 p3 j9 a( Z% k7 Z1 @

减弱胸膜摩擦感：无有（部位）/ b" V |& @' B: S

Subcutaneous crepitus: N Y(posotion) percussion: resonance , ^" u$ E5 j5 J

皮下捻发感无有（部位）叩诊正常清音abnormal dullness flatness hyperresonance tympany" U2 D+ n3 k) Z+ i3 I$ U) P

异常叩诊音浊音实音过清音鼓音! \) K' t; o8 Z: O+ O V: k

Lower borders:scapular line: right intercostal space, left ! V8 c( a: s' O0 V# m' H

肺下界肩胛线右肋间左8 o) H+ O: R6 Q7 Z5 b. ?

intercostal space Range of mobility: right cm , left cm \4 R3 S( V' I5 g' t" d0 J

肋间移动度右cm，左cm Dusculation: breath regular irregular

听诊呼吸规整不规整3 F5 R. y$ |# J; \7 ] Breath sound: normal abnormal( feature, position )

呼吸音正常异常（性质，部位描写）Rale: N Y ：ronchi: sonorous sibilant3 t& L; A4 l: j( m

啰音：无有：干性鼾音哨笛音

Moist rales: coarse medium fine rales crepitus

湿性大中小水泡音捻发音

Vocal conduction: normal abnormal: reduced increased(position)

语音传导正常异常减弱增强（部位）Plueral friction rubs: N Y (position)

胸膜摩擦音无有（部位）

Heart 心6 f0 e$ ?3 l7 ?* B" s- W

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

视诊心前区隆起无有心尖搏动

normal unseen increased diffusing position: normal 9 y0 p7 d$ C0 z6 B5 c. _, j

正常未见增强弥散心尖搏动位置正常- s8 H0 v! G+ T2 J9 x& X

deviation ( the distance from midclavicular line cm)

移动（距左锁骨中线内外厘米）

Other precordial pulsations: N Y (position) 其他部位搏动无有（部位）; c# f: }. Z. _' v; p+ z, K

Palpation:apex impulse:normal increased thrust unclear . m2 h) ~1 R X, T9 S

触诊心尖搏动正常增强抬举感触不清4 L2 \( h( F' l

thrills :N Y (position period) percardial

friction rubs:N Y

震颤无有（部位时期）心包摩擦感无有

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

叩诊相对浊音界正常缩小扩大（右左）; a+ g+ x1 Q6 \- j2 s

Ausculation: heart rate bpm/min rhythm(regular irregular5 X/ L* P& B: ~, I! Y4 R0 z$ H

听诊心率次/分心律（齐不齐）4 q6 ^! K+ f+ G% b

absolutly irrgelar) heart sound:S1 normal increased decreased

绝对不齐心音S1 正常增强减弱* m8 H9 n+ J6 v/ o

split S2 normal increased decreased split/ Q( R# d. d- [# {: X

分裂S2 正常增强减弱分裂. e' y# |' z8 [, X. Z( F- P" f

S3 N Y S4 N Y A2 P2

S3 无有S4 无有A2 P2

Extra heart sound N gallop (diastolic presystotic summalion

额外心音无奔马律（舒张期收缩前期重叠

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

开瓣音其他杂音无有（图示并描述传导）

Pericardial friction rubs N Y- M1 d* y3 g4 {

心包摩擦音无有

Peripheral vessals: normal pistal shot of big arteries

周围血管无异常血管征大血管枪击音. U' M Y- ^4 I/ L( w, u

Duroziez’s sign water hammer pulse capillary pulsation & S; ~8 h& m/ S$ x

二重杂音水冲脉毛细血管搏动* O# l" z/ P) n* h

pulse deficit paradoxical pulse pulsus alternans other

脉搏短绌奇脉交替脉其他

Abdoman 腹部. z( X* L1 A3 }

Inspection: shape normal distention frog abdomen( size cm)

视诊外形正常膨隆蛙腹（腹围厘米）scaphoid apical abdomen gastral pattern intestinal pattern

舟腹尖腹胃型肠型

peristalsis abdominal respiration:existance disappear umbilicus:

蠕动波腹式呼吸存在消失脐" [: q; Q8 p1 e) _6 I( e4 C

normal protruding excretions others: N Y(venous distention of

正常凸出分泌物其他异常无有（腹壁静脉曲张

abdoman purple striae surgical scars hernia)

条纹手术疤痕疝）8 Z C- |5 @: q- J Palpation: soft muscle tension position tenderness N Y

触诊柔软腹肌紧张部位压痛无有rebound tenderness N Y fluidthtill N Y succussions plash N Y5 _+ Q! I, E3 n+ I$ o5 N

反跳痛无有液波震颤无有振水音无有

Mass N Y(position size) discription of feature liver:can’t be 腹部包块无有（部位大小）特征描述肝未触及# I6 r" s% r4 @7 V; W2 h

touched can be touched :subcostal cm under xipfoid process

可触及肋下厘米剑突下

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

特征描述胆囊未触及可触及1 O* X, ~/ j, a" Y

size cm tenderness N Y Murphy’s sign spleen: can’t be 大小厘米压痛无有Murphy征脾未触及

touched can be touched distance from costal margin cm

可触及肋下厘米5 Q7 {" {& I" g: J1 p* { Kideny:can’t be touched can be touched size consistency 9 e7 t6 Z5 h# Z7 \# Q6 F4 q- h

肾未触及可触及大小硬度tenderness mobility tenderness of ureters: N Y (position)

压痛移动度输尿管压痛点无有（部位） _% }. ^5 F9 l) u

percussion: borders of liver dull(existance shrink obliteration )

叩诊肝浊音界（存在缩小消失）- R- B$ {. V$ X t

Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线肋间( r9 W5 z' X" C1 f' `; h shifting dullness N Y tenderness in renal region N Y (right left )6 f7 K1 W& e% Y

移动性浊音无有肾区叩痛无有（右左） ~7 h3 h3 u) Y Q2 D

ausculation : borhorygmus normal increased decreased% y( Y t5 l" r, r, Z1 I

听诊肠鸣音正常增强减弱; g( {4 R9 @5 |! @# T

disappear gurgling N Y vessal bruits N Y (position)

消失气过水声无有血管杂音无有（部位）6 E9 d a& R7 F' A$ E

Genitalia :not examined normal abnormal Rectum and Anus :+ R. S; P% H! Y% ~7 k" u3 p 生殖器未查正常异常肛门直肠9 P; g$ m6 f) n0 p

not examined normal abnormal

未查正常异常

Spine and Extremities

脊柱四肢

Spine : normal deformities (lateral anterior posterior protruding)4 g6 X. w1 p" q' T3 H% {

脊柱正常畸形（侧前后凸）! p9 v# w9 x" \( e5 S

Spinous process : tenderness pain while percussed ( position )

棘突压痛叩痛（部位）) U, v+ Z% ]! O5 m) z: P

Mobility : normal restricted extremeties: normal abnormal * I, q( G$ q) d5 V- D

移动度正常受限四肢正常异常deformity swelling of joints joints stiffness 畸形关节红肿关节强直

tenderness of muscles atrophy of muscles 肌肉压痛肌肉萎缩

Venous distention of lower limbs (position and feature ) acropachy; P8 }7 h9 d% {& f- r' ?1 M/ x

下肢静脉曲张（部位及特征）杵状指

Nervus System

神经系统

Abdominal wall reflex ( normal ) muscle tone ( normal )

腹壁反射（正常）肌张力（正常）Myodynamia ( degree ) paralysis of limbs N Y (left right / X5 g5 |5 g9 S8 P; a

肌力（级）肢体瘫痪无有（左右upper lower) biceps reflex left (normal) right (normal) J7 }* K+ P5 J; \7 ?- h/ ^

上下）肱二头肌反射左（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1 w6 \+ E4 a- A1 L# g

(normal) right ( normal ) : F3 x# m! n7 w! C7 e6 L 正常右（正常）

Hoffmann’s dign left (+)(-) right(+)(-) Hoffmann征左（+）(-) 右（+）（-）Babinski’s sign left(+)（-）right(+)(-) # z: k5 x' P! P" Q3 L

Babinski 左（+）（-）右（+）（-）) h0 o, R+ x' n" H5 N- G

Kernig’s sign left(+)（-）right(+)(-) others7 S0 O) T3 ]+ A3 j

Kernig征左（+）（-）右（+）（-）其他

Laboratory findings

实验室及器械检查结果

（The important laboratory examination .X-ray . ECG and other result areincluded）(重要的化验、X线、心电图及其他有关化验) Nunber of X-ray

X线片号

Abstract

病历摘要

Diagnosis(impressions)" W7 _" b# F6 b3 P/ ]入院诊断