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 姓名年龄性别婚否 xx 民族

Occupation Date of admission Informant 职业住院日期病史表达者病史

主诉

History of present illness

现病史

Past history

既往 xx：

Previous health status:

well ordinary bad Infectious diseases

素来健康情况：

优异一般较差传得病 xx

Immunizations Allergies:

N Y clinical manifestation

预防接种 xxxxxx无有临床表现

allergen:

Trauma:

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Race

History

住院病历的英文

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 ×阳性病史应在下边空间内填写发病时间及简要诊疗经

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

下肢水肿心前区痛苦高血压

Digestive system:

消化系统

Anorexia sour regurgitation belching nausea vomitting

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住院病历的英文

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

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住院病历的英文

polydipsia tremor hands change of character obvious obesity

多饮双手震颤性格改变明显肥胖

emaciation hirsutism hair losing pigmentation

消瘦多毛 xx 零落色素沉着

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

视力阻碍失眠意识阻碍

tremor spasm paralysis paresthesia

颤动抽搐瘫痪感觉异样

Personal history:

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住院病历的英文

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

约年均匀支 / 日戒烟年

alcohol intake N occasional frequent about years

嗜酒无偶有常常约为年

average ml per day others

均匀 ml/ 日其余

Marital history:

婚姻 xx：

结婚年龄配偶健康情况

Menorrhea and Childbearing:

月经及生育 xx

Menarche age cycle lasting for days date of last period

初潮每次连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

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住院病历的英文

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安产

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：

健在生病已故死因母 still alive illness died cause of death siblings:

others:

健在生病已故死因兄弟姐妹儿女其余

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

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住院病历的英文

B.P 血压 mmHg

General Appearance一般情况 :

Development 发育 :

ortho-sthenic type 正常

asthenic type 不良

sthenic type 超凡

nutrition 营养 :

well 优异

fairly 中等

poor 不良

cachexia 恶病质

Facial features 面貌 :

normal 无病容

acute 急性

chronic 慢性病容

others 其余

Expression表情 :

natural 自知

painful 难过

anxious 忧愁

dreadful 惧怕

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住院病历的英文

indifferent 冷漠

Position:

active semi-recumbent others

体位：

自主半卧位其余

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

皮肤粘膜色彩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（种类及分布）Subcutaneous hemorrhange:

N Y(type and distribution)

皮下出血无有（种类及分布）

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住院病历的英文

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 (部位数量 )其余

Lymphnodes:

淋奉承

Superficial lymph nodes:

non-swelling swelling(position and characteristics)

浑身淋奉承肿大无肿大（部位及特色）

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:

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住院病历的英文

tenderness mass sunk (position)

其余异样：

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)

运动阻碍

Sclera :

normal yellow cornea :

normal abnormal ( left right )

巩膜无黄染有黄染角膜正常异样（左右）

Pupils:

equal roundness same size unequal left cm

瞳孔等圆等大不等左 cm

reaction to light:

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住院病历的英文

normal delay (left right) disappear (left right) 对光反射正常愚痴（左右）消逝（左右）

Others:

其余

Ears:

auricle :

normal deformity fistula others (left right )

耳耳廓正常畸形瘘管其余（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阻碍无有（左右）

Nose:

shape :

normal:

abnormal ( ) other abnormalities:

N Y

鼻外形正常异样（）其余异样无有

Nosala flap obsruction excretions nasal sinus tenderness:

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住院病历的英文

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)

异样（苍白出血点）

Opening of parotid gland duct:

normal abnormal (swelling

腮腺导管张口正常异样（肿胀

suppurative excretions)

脓性分泌物）

Tongue:

normal abnormal (coverings tremor leaning to left or right)

舌正常异样（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赤色素沉着

lead line tooth:

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住院病历的英文

regular edentulous carious teeth

铅线牙列齐缺牙 —| —蛀牙 —| —

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加强

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 Hepatojugular reflux:

(-) (+) thyroid:

normal swelling degree

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住院病历的英文

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

侧为主洋溢性结节性质软质硬其余无有

(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 :

乳房正常对称异样左右（男乳女化

mass tenderness excretions of nipples)

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住院病历的英文

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样左

right( increased decreased)

右（加强减弱）

Intercostal space :

normal wide narrow(position)

肋缝隙正常增宽变窄（部位）

Palpation :

vocal fremitus:

normal abnormal :

left right (increased

触诊：

语颤正常异样左右（加强

decreased ) pluernal friction rubs:

N Y（position）

减弱胸膜摩擦感：无有（部位）

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住院病历的英文

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

异样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

肋间挪动度右 cm，左 cm

Dusculation:

breath regular irregular

听诊呼吸规整不规整

Breath sound:

normal abnormal( feature, position )

呼吸音正常异样（性质，部位描述）

Rale:

N Y ：

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住院病历的英文

ronchi:

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)

语音传导正常异样减弱加强（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:

视诊心前区隆起无存心尖搏动

normal unseen increased diffusing position:

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住院病历的英文

normal

正常未见加强弥散心尖搏动地点正常

deviation ( the distance from midclavicular line cm)

挪动（距左锁骨中线内外厘米）

Other precordial pulsations:

N Y (position)

其余部位搏动无有（部位）

Palpation:

apex impulse:

normal increased thrust unclear

触诊心尖搏动正常加强抬举感想不清

thrills :

N Y (position period) percardial friction rubs:

N Y

震颤无有（部位期间）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减小扩大（右左）

Ausculation:

heart rate bpm/min rhythm(regular irregular

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住院病历的英文

听诊心率次 / 分心律（齐不齐）

absolutly irrgelar) heart sound:

S1 normal increased decreased

绝对不同心音 S1正常加强减弱

split S2 normal increased decreased split

S2正常加强减弱

S3NYS4NYA2P2

S3 无有 S4 无有 A2 P2

Extra heart sound N gallop (diastolic presystotic summalion 额外心音无奔马 xx（舒张期缩短先期重叠

gallop) opening snap others murs:

N Y (degree conduction)

开瓣音其余杂音无有（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

四周血管无异样血管征大血管击音

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

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住院病历的英文

脉搏短绌奇脉交替脉其余

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逝脐

normal protruding excretions others:

N Y(venous distention of

正常凸出分泌物其余异样无有（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

触诊柔嫩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

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住院病历的英文

Mass N Y(position size) discription of feature liver:

can ’ t be腹部包块无有（部位大小）特色描述肝未涉及

touched can be touched :

subcostal cm under xipfoid process

可涉及肋下厘米剑突下

discription of feature gallbladder:

can ’ t be touched can be touched

特色描述胆囊未涉及可涉及

size cm tenderness N Y Murphy ’ s sign spleen:

can ’ t be大小厘米压痛无有 Murphy 征脾未涉及

touched can be touched distance from costal margin cm

可涉及肋下厘米

Kideny:

can ’ t be touched can be touched size consistency

肾未涉及可涉及大小硬度

tenderness mobility tenderness of ureters:

N Y (position)

压痛挪动度输尿管压痛点无有（部位）

percussion:

borders of liver dull(existance shrink obliteration )

叩诊肝浊音界（存在减小消逝）

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住院病历的英文

Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线肋间

shifting dullness N Y tenderness in renal region N Y (right left )

挪动性浊音无有肾区叩痛无有（右左）

ausculation :

borhorygmus normal increased decreased

听诊肠鸣音正常加强减弱

disappear gurgling N Y vessal bruits N Y (position)

消逝气过水声无有血管杂音无有（部位）

Genitalia :

not examined normal abnormal Rectum and Anus :

生殖器未查正常异样肛门直肠

not examined normal abnormal

未查正常异样

Spine and Extremities

脊柱四肢

Spine :

normal deformities (lateral anterior posterior protruding)

脊柱正常畸形（侧前后凸）

Spinous process :

tenderness pain while percussed ( position )

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住院病历的英文

棘突压痛叩痛（部位）

Mobility :

normal restricted extremeties:

normal abnormal

挪动度正常受限四肢正常异样

deformity swelling of joints joints stiffness

畸形关节红肿关节强直

tenderness of muscles atrophy of muscles

肌肉压痛肌肉萎缩

Venous distention of lower limbs (position and feature ) acropachy

下肢静脉曲张（部位及特色）杵状指

Nervus System

神经系统

Abdominal wall reflex ( normal ) muscle tone ( normal )

腹壁反射（正常）肌张力（正常）

Myodynamia ( degree ) paralysis of limbs N Y (left right

肌力（级）肢体瘫痪无有（左右

upper lower) biceps reflex left (normal) right (normal)

上下）肱二头肌反射左（正常）右（正常） knee jerk left (normal) right( normal) achilles jerk left

膝健反射左（正常）右（正常）跟腱反射左

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住院病历的英文

(normal) right ( normal )

正常右（正常）

Hoffmann ’ s dign left (+)(-right(+)(-)

Hoffmann 征左（ +）(-)右（ +）（ -）

Babinski ’ s sign left(+)（-）right(+)(-)

Babinski 左（ +）（ -）右（ +）（ -）

Kernig ’ s sign left(+)（-）right(+)(-) others

Kernig 征左（ +）（ -）右（ +）（ -）其余

Laboratory findings

实验室及器材检查结果

（ The important laboratory examination .X-ray . ECG and other result areincluded）(重要的化验、余有关化验 ) Nunber of X-ray

X 线片号

Abstract

病历大纲

Diagnosis(impressions)

住院诊疗

Recorder

病史记录者

Examiner

并使批阅者

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线、心电图及其

X 住院病历的英文

Date of record

记录日期

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