住院病历中英文对照.pdfVIP

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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-OrientedMedicalRecords)表格式住院病历

Biographicaldata:

一般项目：

NameAgeSexMaritalstatusNativityRace

姓名年龄性别婚否籍贯民族

OccupationDateofadmissionInformantHistory

职业入院日期病史叙述者病史

Chiefcomplaint

主诉

Historyofpresentillness

现病史

Pasthistory

既往史：

Previoushealthstatus:wellordinarybadInfectiousdiseases

平素健康状况：良好一般较差传染病史

ImmunizationsAllergies:NYclinicalmanifestation

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

Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpostive,youshouldwritedownyour

diseasehistoryandbriefcourseofdiagnoseandtherapy)

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)

Respiratorysystem:

呼吸系统

Sorethroatchroniccoughsputumhemoptysiswheezing

咽痛慢性咳嗽咳痰咯血哮喘

dyspneachestpain

呼吸困难胸痛

cadiovascularsystem:

循环系统

Palpitationdyspneaonexertionhemoptysissyncope

心悸活动后气促咯血晕厥

edemaoflowerlimbsprecordialpainhypertention

下肢水肿心前区疼痛高血压

Digestivesystem:

消化系统

Anorexiasourregurgitationbelchingnauseavomitting

食欲减退反酸嗳气恶心呕吐

abdominaldistentionabdominalpainconstipationdiarrhea

腹胀腹痛便秘腹泻

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hematemesismelenahematocheziajaundice

呕血黑便便血黄疸

Urinarysystem:

泌尿系统

Lumbagofrequentmicturitionurgentmicturitionurodynia

腰痛尿频尿急尿痛

dysuriahematurianocturiapolyuriaoliguriafacialedema

排尿困难血尿夜尿多尿少尿面部水肿

Hematopoieticsystem

造血系统

Fatiguedizzinessblurredvisiongingivalbleedig

乏力头昏牙龈出血

subcutaneoushemorrhageostealgiaepistaxis

皮下出血骨痛鼻衄

Metabolicandendocrinesystem:

代谢及内分泌系统

Excessiveappetiteanorexiasweatscoldintolerance

食欲亢进食欲减退多汗畏寒

polydipsiatremorhandschangeofcharacterobviousobesity

多饮双手震颤性格改变显著肥胖

emaciationhirsutismhairlosingpigmentation

消瘦