住院病历中英文对照

随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！

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

Biographical data:

一般项目：

Name Age Sex Marital status Nativity Race

姓名年龄性别婚否籍贯民族

Occupation Date of admission Informant History

职业入院日期病史叙述者病史

Chief complaint

主诉

History of present illness

现病史

Past history

既往史：

Previous health status: well ordinary bad Infectious diseases

平素健康状况：良好一般较差传染病史

Immunizations Allergies: N Y clinical manifestation

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

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) Respiratory system:

呼吸系统

Sore throat chronic cough sputum hemoptysis wheezing

咽痛慢性咳嗽咳痰咯血哮喘

dyspnea chest pain

呼吸困难胸痛

cadiovascular system:

循环系统

Palpitation dyspnea on exertion hemoptysis syncope

心悸活动后气促咯血晕厥

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