文档介绍：住院病历的英汉对照来源: 孙亮亮的日志
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
plaint
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 syn