病历中英对照.docVIP

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 degeneratio