1、表格式住院病例中英版比較表格式住院病例中英版比較精選文檔表格式住院病例中英版比較POMR(Problem-OrientedMedicalRecords)表格式住院病歷Biographicaldata:一般項目：NameAgeSexMaritalstatusNativityRace姓名年紀(jì)性別婚否籍貫民族OccupationDateofadmissionInformantHistory職業(yè)住院日期病史表達者病史Chiefcomplaint主訴Historyofpresentillness現(xiàn)病史Pasthistory既往史：Previoushealthstatus:wellordinarybadI

2、nfectiousdiseases向來健康情況：優(yōu)秀一般較差傳患病史ImmunizationsAllergies:NYclinicalmanifestation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Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpostive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)系統(tǒng)回首：(有打無打陽性病史應(yīng)在下邊空間內(nèi)填寫發(fā)病時間及簡要診斷經(jīng)過)Respir

3、atorysystem:呼吸系統(tǒng)Sorethroatchroniccoughsputumhemoptysiswheezing咽痛慢性咳嗽咳痰咯血哮喘dyspneachestpain呼吸困難胸痛cadiovascularsystem:循環(huán)系統(tǒng)Palpitationdyspneaonexertionhemoptysissyncope心悸活動后氣促咯血暈厥edemaoflowerlimbsprecordialpainhypertention下肢水腫心前區(qū)傷心高血壓Digestivesystem:消化系統(tǒng)Anorexiasourregurgitationbelchingnauseavomitting食

4、欲減退反酸噯氣惡心嘔吐abdominaldistentionabdominalpainconstipationdiarrhea腹脹腹痛便秘腹瀉hematemesismelenahematocheziajaundice嘔血黑便便血黃疸Urinarysystem:泌尿系統(tǒng)Lumbagofrequentmicturitionurgentmicturitionurodynia腰痛尿頻尿急尿痛dysuriahematurianocturiapolyuriaoliguriafacialedema排尿困難血尿夜尿多尿少尿面部水腫Hematopoieticsystem造血系統(tǒng)Fatiguedizzinessb

5、lurredvisiongingivalbleedig乏力頭昏牙齦出血subcutaneoushemorrhageostealgiaepistaxis皮下出血骨痛鼻衄Metabolicandendocrinesystem:代謝及內(nèi)分泌系統(tǒng)Excessiveappetiteanorexiasweatscoldintolerance食欲亢進食欲減退多汗畏寒polydipsiatremorhandschangeofcharacterobviousobesity多飲雙手震顫性格改變明顯肥胖emaciationhirsutismhairlosingpigmentation消瘦多毛毛發(fā)零落色素沉穩(wěn)chan

6、gofsexualfunctionamenorrhea性功能改變閉經(jīng)Musculoskeletalsystem肌肉骨骼系統(tǒng)Floatingarthralgiaarthraligaswellingofjoints游走性關(guān)節(jié)痛關(guān)節(jié)痛關(guān)節(jié)紅腫deformiteiesofjiontsmyalgiaatrophyofmuscle關(guān)節(jié)變形肌肉痛肌肉萎縮Nervoussystem神經(jīng)系統(tǒng)Dizzinessheadachevertigosyncopedegenerationofmemory頭昏頭痛眩暈暈厥記憶力減退visualdisturbanceinsomniadisturbanceofconsciousn

7、ess視力阻攔失眠意識阻攔tremorspasmparalysisparesthesia抖動抽搐癱瘓感覺異樣Personalhistory:個人史BirthplaceOccupationsexualhistorysmokingNY出生地職業(yè)冶游史抽煙無有aboutyearsaveragepiecesperdayceasedforyears約年均勻支/日戒煙年alcoholintakeNoccasionalfrequentaboutyears嗜酒無偶有常常約為年averagemlperdayothers均勻ml/日其余Maritalhistory:婚姻史：Marryingagecompanion

8、sstateofhealth成婚年紀(jì)配偶健康情況MenorrheaandChildbearing:月經(jīng)及生育史Menarcheagecyclelastingfordaysdateoflastperiod初潮每次連續(xù)時間末次月經(jīng)時間(ageofmenopause)絕經(jīng)年紀(jì)Amountofflow:littlenormallargemenstrualpain:NY經(jīng)量少正常多痛經(jīng)無有cycle:regularirregularpregnancytimesnaturallabor經(jīng)期規(guī)則不規(guī)則妊娠次安產(chǎn)timesabortionstimesprematuredeliverytimes胎流產(chǎn)胎早產(chǎn)胎s

9、tillbirthstimesdifficultlaboranditscondition死產(chǎn)胎難產(chǎn)及病情Famillyhistory(payattentiontothecongenitaldiseasesandcommunicablediseasesandcommunicabledieasesrelatedtothepaitent家族史（注意與患者現(xiàn)病相關(guān)的遺傳病和傳染性疾?。〧ather:stillaliveillnessdiedcauseofdeathsmother:父：健在患病已故死因母stillaliveillnessdiedcauseofdeathsiblings:others:健在

10、患病已故死因兄弟姐妹兒女其余Physicalexamination體格檢查Vitalsigns生命體征:Temperature體溫pulse脈搏/min次/分respiration呼吸/min次/分B.P血壓mmHgGeneralAppearance一般情況:Development發(fā)育:ortho-sthenictype正常asthenictype不良sthenictype超凡nutrition營養(yǎng):well優(yōu)秀fairly中等poor不良cachexia惡病質(zhì)Facialfeatures容顏:normal無病容acute急性chronic慢性病容others其余Expression表情:na

11、tural自知painful傷心anxious憂愁dreadful懼怕indifferent冷淡Position:activesemi-recumbentothers體位：自主半臥位其余Gait:normalabnormal步態(tài)正常不正常Conciousness:awaresomnolenceconfusionstuporcoma神志清楚嗜睡模糊昏睡昏倒deliriumcoppperatio;wellbadly譫妄配合檢查合作不合作Mucocutaneouscolor:normalredpalecyaosisstainted皮膚粘膜色彩無病容潮紅蒼白紫紺yellowpigmentationle

12、sions:NY(typeanddistribution)黃染色素沉穩(wěn)皮疹無有（種類及散布）Subcutaneoushemorrhange:NY(typeanddistribution)皮下出血無有（種類及散布）Hair:normalreducededema:NY(positionanddegree)頭發(fā)散布正常減退水腫無有（部位及程度）Hepaticpalm:NYspiderangionma:NY（positionnumbers）others:肝掌無有蜘蛛痣無有(部位數(shù)量)其余Lymphnodes:淋奉承Superficiallymphnodes:non-swellingswelling(p

13、ositionandcharacteristics)渾身淋奉承腫大無腫大腫大（部位及特點）Head:cranium:size:normallargesmalldeformity:頭部頭顱大小正常大小畸形NY(coxycephalysquaredskulldeformingskull)無有（尖顱方顱變形顱）Others:tendernessmasssunk(position)其余異樣：壓痛包塊凹陷（部位）Eyeseyelid:normaledemaptosistrichiasisconjunctive:眼瞼正常水腫下垂倒睫結(jié)膜normalhyperemiaedemahemrrhage正常充血水腫

14、出血eyeball:normalproptosisdepressiontremor眼球正常突出凹陷震顫motiondysfunction(leftright)運動阻攔Sclera:normalyellowcornea:normalabnormal(leftright)鞏膜無黃染有黃染角膜正常異樣（左右）Pupils:equalroundnesssamesizeunequalleftcm瞳孔等圓等大不等左cmreactiontolight:normaldelay(leftright)disappear(leftright)對光反射正常愚癡（左右）消逝（左右）Others:其余Ears:auric

15、le:normaldeformityfistulaothers(leftright)耳耳廓正?；委浌芷溆啵ㄗ笥遥〆xcretionsofexternalauditorycanal:NY(leftrightfeature)外耳道分泌物無有（左右性質(zhì)）Tendernessofmastoid:NYaudationdysfunction:NY(leftright)乳突壓痛無有聽力粗試阻攔無有（左右）Nose:shape:normal:abnormal()otherabnormalities:NY鼻外形正常異樣（）其余異樣無有Nosalalaflapobsructionexcretionsnasals

16、inustenderness:鼻翼扇動鼻塞分泌物鼻旁竇壓痛NY(position)無有（部位）Mouthlips:redsyanosispaleherpesfissuremucosa:normal口唇紅潤發(fā)紺蒼白皰疹皸裂粘膜正常abnormal(palepetechia)異樣（蒼白出血點）Openingofparotidglandduct:normalabnormal(swelling腮腺導(dǎo)管張口正常異樣（腫脹suppurativeexcretions)膿性分泌物）Tongue:normalabnormal(coveringstremorleaningtoleftorright)舌正常異樣（舌

17、苔伸舌震顫向左、向右偏斜）Gums:normalswellingpusoverflowhemorrhagepigments牙齦正常腫脹溢膿出血色素沉穩(wěn)leadlinetooth:regularedentulouscariousteeth鉛線牙列齊缺牙|蛀牙|Tonsils:pharynx:voice:normalhoarse扁桃體咽聲音正常沙啞Neck:resistence:NYcarotidarterypulsation:normalincreased頸部抵擋感無有頸動脈搏動正常加強decreased(leftright)jugularvein:normaldistention減弱（左右）頸

18、靜脈正常充盈highdistentiontrachea:middledeviationto(leftright)怒張氣管正中偏移（向左向右）Hepatojugularreflux:(-)(+)thyroid:normalswellingdegree肝頸靜脈回流征：（-）（+）甲狀腺正常腫大度Symmetry對稱Dominanceinoneside:spreadingnodular:softhardothers:NY側(cè)為主洋溢性結(jié)節(jié)性質(zhì)軟質(zhì)硬其余無有(tendernesstremorbruits)（壓痛震顫血管雜音）Chesttopography:normalbarrelchestpigeonc

19、hestfunnelchest胸部胸廓正常桶狀胸雞胸漏斗胸flatchestbulgingorretraction(leftright)扁平胸膨隆或凹陷（左右）bulgingintheprecordialregiontendernessofsternum心前區(qū)膨隆胸骨壓痛Breast:normalsymmetricalabnormal:leftright(gynecomastia乳房正常對稱異樣左右（男乳女化masstendernessexcretionsofnipples)包塊壓痛乳頭分泌物）Lung肺Inspection:movementofrespiration:normalabnorm

20、al:left視診呼吸運動正常異樣左right(increaseddecreased)右（加強減弱）Intercostalspace:normalwidenarrow(position)肋空隙正常增寬變窄（部位）Palpation:vocalfremitus:normalabnormal:leftright(increased觸診：語顫正常異樣左右（加強decreased)pluernalfrictionrubs:NY（position）減弱胸膜摩擦感：無有（部位）Subcutaneouscrepitus:NY(posotion)percussion:resonance皮下捻發(fā)感無有（部位）叩

21、診正常清音abnormaldullnessflatnesshyperresonancetympany異樣叩診音濁音實音過清音鼓音Lowerborders:scapularline:rightintercostalspace,left肺下界肩胛線右肋間左intercostalspaceRangeofmobility:rightcm,leftcm肋間挪動度右cm，左cmDusculation:breathregularirregular聽診呼吸規(guī)整不規(guī)整Breathsound:normalabnormal(feature,position)呼吸音正常異樣（性質(zhì)，部位描繪）Rale:NY：ronch

22、i:sonoroussibilant啰音：無有：干性鼾音哨笛音Moistrales:coarsemediumfineralescrepitus濕性大中小水泡音捻發(fā)音Vocalconduction:normalabnormal:reducedincreased(position)語音傳導(dǎo)正常異樣減弱加強（部位）Plueralfrictionrubs:NY(position)胸膜摩擦音無有（部位）Heart心Inspection:bulginginprecordialregion:NYapeximpulse:視診心前區(qū)隆起無有心尖搏動normalunseenincreaseddiffusingpo

23、sition:normal正常未見加強彌散心尖搏動地點正常deviation(thedistancefrommidclavicularlinecm)挪動（距左鎖骨中線內(nèi)外厘米）Otherprecordialpulsations:NY(position)其余部位搏動無有（部位）Palpation:apeximpulse:normalincreasedthrustunclear觸診心尖搏動正常加強抬舉感觸不清thrills:NY(positionperiod)percardialfrictionrubs:NY震顫無有（部位時期）心包摩擦感無有Percussion:relativecardiacou

24、tline:normalshrinkextant(rightleft)叩診相對濁音界正常減小擴大（右左）Ausculation:heartratebpm/minrhythm(regularirregular聽診心率次/分心律（齊不齊）absolutlyirrgelar)heartsound:S1normalincreaseddecreased絕對不齊心音S1正常加強減弱splitS2normalincreaseddecreasedsplit分裂S2正常加強減弱分裂S3NYS4NYA2P2S3無有S4無有A2P2ExtraheartsoundNgallop(diastolicpresystoti

25、csummalion額外心音無奔馬律（舒張期縮短先期重疊gallop)openingsnapothersmurmurs:NY(degreeconduction)開瓣音其余雜音無有（圖示并描繪傳導(dǎo)）PericardialfrictionrubsNY心包摩擦音無有Peripheralvessals:normalpistalshotofbigarteries四周血管無異樣血管征大血管槍擊音Duroziezssignwaterhammerpulsecapillarypulsation二重雜音水沖脈毛細血管搏動pulsedeficitparadoxicalpulsepulsusalternansothe

26、r脈搏短絀奇脈交替脈其余Abdoman腹部Inspection:shapenormaldistentionfrogabdomen(sizecm)視診外形正常膨隆蛙腹（腹圍厘米）scaphoidapicalabdomengastralpatternintestinalpattern舟腹尖腹胃型腸型peristalsisabdominalrespiration:existancedisappearumbilicus:蠕動波腹式呼吸存在消逝臍normalprotrudingexcretionsothers:NY(venousdistentionof正常凸出分泌物其余異樣無有（腹壁靜脈曲張abdoma

27、npurplestriaesurgicalscarshernia)條紋手術(shù)疤痕疝）Palpation:softmuscletensionpositiontendernessNY觸診嬌貴腹肌緊張部位壓痛無有reboundtendernessNYfluidthtillNYsuccussionsplashNY反跳痛無有液波震顫無有振水音無有MassNY(positionsize)discriptionoffeatureliver:cantbe腹部包塊無有（部位大小）特點描繪肝未涉及touchedcanbetouched:subcostalcmunderxipfoidprocess可涉及肋下厘米劍突下

28、discriptionoffeaturegallbladder:cantbetouchedcanbetouched特點描繪膽囊未涉及可涉及sizecmtendernessNYMurphyssignspleen:cantbe大小厘米壓痛無有Murphy征脾未涉及touchedcanbetoucheddistancefromcostalmargincm可涉及肋下厘米Kideny:cantbetouchedcanbetouchedsizeconsistency腎未涉及可涉及大小硬度tendernessmobilitytendernessofureters:NY(position)壓痛挪動度輸尿管壓痛

29、點無有（部位）percussion:bordersofliverdull(existanceshrinkobliteration)叩診肝濁音界（存在減小消逝）Upperbordersofliveronrightmidclavicularlineintercostalspace肝上界位于右鎖骨中線肋間shiftingdullnessNYtendernessinrenalregionNY(rightleft)挪動性濁音無有腎區(qū)叩痛無有（右左）ausculation:borhorygmusnormalincreaseddecreased聽診腸鳴音正常加強減弱disappeargurglingNYvessalbruitsNY(position)消逝氣過水聲無有血管雜音無有（部位）Genitalia:notexaminednormalabnormalRectumandAnus:生殖器未查正常異樣肛門直腸notexaminednormalabnormal未查正常異樣SpineandExtremities脊柱四肢Spine:normaldeformities(lateralanteriorposteriorprotruding)脊柱正常