住院病历的英文

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xx民族

Occupation Date of admission Informant History

职业入院日期病史叙述者病史

主诉

History of present illness

现病史

Past history

既往xx：

Previous health status:

well ordinary bad Infectious diseases

平素健康状况：

良好一般较差传染病xx

Immunizations Allergies:

N Y clinical manifestation

预防接种xxxxxx无有临床表现

allergen:

Trauma:

Surgery:

过敏原外伤xx手术xx

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xx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xx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xx

Birthplace Occupation sexual history smoking N Y

出生地职业冶游xx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xx：

结婚年龄配偶健康状况

Menorrhea and Childbearing:

月经及生育xx

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

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:

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（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

Nosala 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xx气管正中偏移（向xx）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 :

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）

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 ：

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:

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xx（舒张期收缩前期重叠

gallop) opening snap others murs:

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