住院病历专业名词.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 degeneration of memory头昏 头