住院病历中英文对照-精

2020-12-12

【关键字】空间、系统、自主、良好、健康、持续、合作、配合、位置、突出、意识、增强、扩大、外心

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 hypertention

下肢水肿心前区疼痛高血压

Digestive system:

消化系统

Anorexia sour regurgitation belching nausea vomitting

食欲减退反酸嗳气恶心呕吐abdominal distention abdominal pain constipation diarrhea

腹胀腹痛便秘腹泻

hematemesis melena hematochezia jaundice

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

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

subcutaneous hemorrhage ostealgia epistaxis

皮下出血骨痛鼻衄

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polydipsia tremor hands change of character obvious obesity

多饮双手震颤性格改变显著肥胖

emaciation hirsutism hair losing pigmentation

消瘦多毛毛发脱落色素沉着

chang of sexual function amenorrhea

性功能改变闭经

Musculoskeletal system

肌肉骨骼系统

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

关节变形肌肉痛肌肉萎缩

Nervous system

神经系统

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

视力障碍失眠意识障碍

tremor spasm paralysis paresthesia

颤动抽搐瘫痪感觉异常

Personal history:

个人史

Birthplace Occupation sexual history smoking N Y

出生地职业冶游史吸烟无有

about years average pieces per day ceased for years

约年平均支/日戒烟年

alcohol intake N occasional frequent about years

嗜酒无偶有经常约为年

average ml per day others

平均ml/日其他

Marital history:

婚姻史：

Marrying age companion’s state of health 结婚年龄配偶健康状况

Menorrhea and Childbearing:

月经及生育史Menarche age cycle lasting for days date of last period

初潮每次持续时间末次月经时间

(age of menopause)

绝经年龄

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

经期规则不规则妊娠次顺产

times abortions times premature delivery times

胎流产胎早产胎

stillbirths times difficult labor and its condition

死产胎难产及病情

Familly history (pay attention to the congenital diseases and communicable diseases and communicable dieases related to the paitent

家族史（注意与患者现病有关的遗传病和传染性疾病）

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体格检查

Vital signs生命体征:

Temperature体温

pulse脉搏/min次/分

respiration呼吸/min次/分

B.P血压mmHg

General Appearance一般状况: Development发育:

ortho-sthenic type正常

asthenic type不良

sthenic type超常

nutrition营养:

well良好

fairly中等

poor不良

cachexia恶病质

Facial features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: active semi-recumbent others

体位：自主半卧位其他

Gait: normal abnormal

步态正常不正常

Conciousness: aware somnolence confusion stupor coma

神志清楚嗜睡模糊昏睡昏迷delirium coppperatio; well badly

谵妄配合检查合作不合作Mucocutaneous color: normal red pale cyaosis stainted

皮肤粘膜色泽无病容潮红苍白紫绀yellow pigmentation lesions:N Y (type and distribution)

黄染色素沉着皮疹无有（类型及分布）Subcutaneous hemorrhange: N Y(type and distribution)

皮下出血无有（类型及分布）

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

头发分布正常减退水肿无有（部位及程度）

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

肝掌无有蜘蛛痣无有(部位数目) 其他

Lymphnodes:

淋巴结

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

全身淋巴结肿大无肿大肿大（部位及特征）

Head : cranium : size : normal large small deformity:

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）

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

normal hyperemia edema hemrrhage

正常充血水肿出血

eye ball: normal proptosis depression tremor

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）

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）

Others:

其他

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

耳耳廓正常畸形瘘管其他（左右）

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

外耳道分泌物无有（左右性质）Tenderness of mastoid : N Y audation dysfunction: N Y (left right)

乳突压痛无有听力粗试障碍无有（左右）

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

鼻外形正常异常（）其他异常无有Nosalala flap obsruction excretions nasal sinus tenderness:

鼻翼扇动鼻塞分泌物鼻旁窦压痛

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

abnormal ( pale petechia)

异常（苍白出血点）

Opening of parotid gland duct: normal abnormal (swelling

腮腺导管开口正常异常（肿胀suppurative excretions)

脓性分泌物）

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

舌正常异常（舌苔伸舌震颤向左、向右偏斜）

Gums: normal swelling pus overflow hemorrhage pigments

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—|—Tonsils: pharynx: voice: normal hoarse

扁桃体咽声音正常嘶哑

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)

怒张气管正中偏移（向左向右）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

(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

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

心前区膨隆胸骨压痛

Breast: normal symmetrical abnormal : left right(gynecomastia

乳房正常对称异常左右（男乳女化mass tenderness excretions of nipples)

包块压痛乳头分泌物）

Recorder

病史记录者

Examiner

并使审阅者

Date of record

记录日期

Lung

肺

Inspection : movement of respiration : normal abnormal : left

视诊呼吸运动正常异常左

right( increased decreased)

右（增强减弱）

Intercostal space :normal wide narrow(position)

肋间隙正常增宽变窄（部位）Palpation : vocal fremitus:normal abnormal :left right (increased

触诊：语颤正常异常左右（增强decreased ) pluernal friction rubs: N Y （position）

减弱胸膜摩擦感：无有（部位）Subcutaneous crepitus: N Y(posotion) percussion: resonance

皮下捻发感无有（部位）叩诊正常清音abnormal dullness flatness hyperresonance tympany

异常叩诊音浊音实音过清音鼓音Lower borders:scapular line: right intercostal space, left

肺下界肩胛线右肋间左

intercostal space Range of mobility: right cm , left cm

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

听诊呼吸规整不规整

Breath sound: normal abnormal( feature, position )

呼吸音正常异常（性质，部位描写）Rale: N Y ：ronchi: sonorous sibilant

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

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

正常未见增强弥散心尖搏动位置正常

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）Palpation:apex impulse:normal increased thrust unclear

触诊心尖搏动正常增强抬举感触不清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）

Ausculation: heart rate bpm/min rhythm(regular irregular

听诊心率次/分心律（齐不齐）absolutly irrgelar) heart sound:S1 normal increased decreased

绝对不齐心音S1 正常增强减弱

split S2 normal increased decreased split 分裂S2 正常增强减弱分裂

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

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Duroziez’s sign water hammer pulse capillary pulsation

二重杂音水冲脉毛细血管搏动

pulse deficit paradoxical pulse pulsus alternans other

脉搏短绌奇脉交替脉其他Abdoman

腹部

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

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）

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 Y

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

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

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

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

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）percussion: borders of liver dull(existance shrink obliteration )

叩诊肝浊音界（存在缩小消失）Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线肋间

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

移动性浊音无有肾区叩痛无有（右左）

ausculation : borhorygmus normal increased decreased

听诊肠鸣音正常增强减弱

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）

Genitalia :not examined normal abnormal Rectum and Anus :

生殖器未查正常异常肛门直肠

not examined normal abnormal

未查正常异常

Spine and Extremities

脊柱四肢

Spine : normal deformities (lateral anterior posterior protruding)

脊柱正常畸形（侧前后凸）Spinous process : tenderness pain while percussed ( position )

棘突压痛叩痛（部位）Mobility : normal restricted extremeties: normal abnormal

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

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

肌力（级）肢体瘫痪无有（左右upper lower) biceps reflex left (normal) right (normal)

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

(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

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)

入院诊断