住院病历中英文对照

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-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xx民族
Occupati on Date of admissi on Informa nt History
职业入院日期病史叙述者病史
主诉
History of present illness
现病史
Past history
既往xx：
Previous health status:
well ordinary bad Infectious diseases
平素健康状况：
良好一般较差传染病xx
Immun izations Allergies:
N Y clinical manifestation
预防接种xxxxxx无有临床表现
allerge n:
Trauma:
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V无打X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:
循坏系统
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
食欲减退反酸暧气恶心呕吐
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 freque nt micturition urge nt micturitio n urod ynia 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ffil
Metabolic and endocrine system:
代谢及内分泌系统
Excessive appetite anorexia sweats cold intoleranee
食欲亢进食欲减退XX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XX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 disturbs nee insom nia disturbs nee of conscious ness 视力障碍失眠意识障碍
tremor spasm paralysis paresthesia
颤动抽搐瘫痪感觉异常
Personal history:
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 约年平均支/日戒烟年
alcoho I in take N occasional frequent about years
嗜酒无偶有经常约为年
average ml per day others
平均ml/日其他
Marital history:
婚姻XX：
结婚年龄配偶健康状况
Menorrhea and Childbearing:
月经及生育XX
Menarche age cycle lasting for days date of last period 初潮每次持续时间末次月经时间
(age of menopause)
绝经年龄
Amount of flow:
little normal large menstrual pain:
NY
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顺产
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 Father:
still alive illness died cause of deaths mother:
父：
健在患病已故死因母still alive illness died cause of death siblings: others:
健在患病已故死因兄弟姐妹子女其他
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
B.P 血压mmHg
General Appearanee —般状况:
Development 发育：ortho-sthenictype 正常asthenic type 不良sthenic type 超常nutrition 营养：
well良好
fairly中等
poor不良
cachexia恶病质
Facial features 面容:
normal无病容
acute急性
chronic慢性病容
others其他
Expression 表情：
natural 自知
painful 痛苦
anxious 忧虑
dreadful 恐惧
indifferent 淡漠
Positio n:
active semi-recumbent others
体位：
自主半卧位其他
Gait:
normal abnormal
步态正常不正常
Concious ness:
神志清楚嗜唾模糊昏睡昏迷delirium coppperatio; well badly
请妄配合检查合作不合作Mucocutaneous color:
normal red pale cyaosis stainted
皮肤粘膜色泽无病容潮红苍白紫纟甘yellow pigmentation lesions:
N Y (type and distribution)
黄染色素沉着皮疹无有(类型及分布) Subcutaneous hemorrhange:
N Y(type and distribution)
皮下出血无有(类型及分布)
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 (positionnumbers )
肝掌无有蜘蛛痣others:
无有(部位数目)其他
Lymph no des:
淋巴结
Superficial lymph no des:
non-swelling swelling(position and characteristics)全身淋巴结肿大无肿大 (部位及特征)
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:
tenderness mass sunk (position)
其他异常：
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)
运动障碍
Sclera :
normal yellow cornea :
normal abnormal (left right)
巩膜无黄染有黄染角膜正常异常(左右)
Pupils:
equal roundness same size unequal left cm
瞳孔等圆等人不等左cm
reaction to light:
normal delay (left right) disappear (left right)对光反射正常迟钝(左右)消失 (左右)
Others:
其他
Ears:
auricle :
normal deformity fistula others (left right)
耳耳廓正常畸形痿管其他(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障碍无有(左右)
Nose:
shape :
n ormal:
abnormal () other abnormalities:
NY
鼻外形正常异常()其他异常无有
Nosala flap obsruction excretions nasal sinus tenderness: 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 :
n ormal
口唇红润发纟甘苍白疱疹皴裂粘月莫正常
abnormal ( pale petechia)
异常(苍白出血点)
Opening of parotid gland duct:
normal abnormal (swelling
腮腺导管开口正常异常(肿胀
suppurative excretions)
脓性分泌物)
Tongue:
normal abnormal (coverings tremor leaning to left or right) 舌正常异常(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血色素沉着
lead line tooth:
regular edentulous carious teeth
铅线牙列齐缺牙一I —齿禹齿一I —
Tonsils:
phar ynx:
voice:
normal hoarse
扁桃体咽声音正常嘶哑
Neck:
resiste nee:
N Y carotid artery pulsation:
n ormal in creased
颈部抵抗感无有颈动脉搏动正常增强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xx) Hepatojugular reflux:
(-)(+) thyroid:
normal swelling degree
肝颈静脉回流征：
(・)(+)甲状腺正常肿大度Symmetry 对称
Domi nance in one side:
preading nodular:
soft hard others :
NY
侧为主弥漫性结节性质软质硬其他无有(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 :
乳房正常对称异常左右（男乳女化
mass tenderness excretions of nipples）
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常左
right（ in creased decreased）
右（增强减弱）
Intercostal space :
normal wide narrow（position）肋间隙正常增宽变窄（部位）Palpation :
vocal fremitus:
normal abnormal:
left right （increased
触诊：
语颤正常异常左右（增强decreased ) pluernal friction rubs: N Y (position)
减弱胸膜摩擦感：
无有(部位)
Subcutaneous crepitus:
N Y(posotion) percussion:
res on ance
皮下捻发感无有(部位)叩诊正常清音
abnormal dullness flatness hyperresonance tympany
异常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
肋间移动度右cm,左cm
Dusculatio n:
breath regular irregular
听诊呼吸规整不规整
Breath sound:
normal abnormal( feature, position ) 呼吸音正常异常(性质，部位描写) Rale: NY :
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)
语音传导正常异常减弱增强(部位) Plueral friction rubs:
N Y (position)
胸膜摩擦音无有(部位)
Heart 心
In specti on:
bulging in precordial region :
N Y apex impulse:
视诊心前区隆起无有心尖搏动
n ormal un see n in creased diffusi ng positi on: n ormal
正常未见增强弥散心尖搏动位置正常
deviation (the distanee from midclavicular line cm)
移动(距左锁骨中线内外厘米)
Other precordial pulsations:
N Y (position)
其他部位搏动无有(部位)
Palpation:
apex impulse:
normal increased thrust unclear
触诊心尖搏动正常增强抬举感触不清
thrills :
N Y (position period) percardial friction rubs:
NY
震颤无有(部位时期)心包摩擦感无有
Percussion:
relative cardiac outline:
normal shrink extant （right left ）PP诊相对浊音界正常缩小扩大（右左）Ausculatio n:
heart rate bpm/min rhythm（regular irregular
听诊心率次/分心律（齐不齐）
absolutly irrgelar） heart sound:
SI
n ormal in creased decreased
绝对不齐心音si正常增强减弱
split S2 n ormal in creased decreased split
分裂S2正常增强减弱分裂
S3 N Y S4 N Y A2 P2
S3无有S4无有A2 P2
Extra heart sound N gallop （diastolic presystotic summalion 额外心音无奔马XX （舒张期收缩前期重叠
gallop） opening snap others murs:
N Y （degree conduction）
开瓣音其他杂音无有（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
周围血管无异常血管征大血管枪击音
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 alter nans other
脉搏短细奇脉交替脉其他
Abdoma n
腹部
In specti on:
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:
existanee disappear umbilicus:
蠕动波腹式呼吸存在消失脐
normal protruding excretions others:
N Y（venous distention of
正常凸出分泌物其他异常无有（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
触诊柔软腹肌紧张部位压痛无有rebound tenderness N Yfluidthtill N Y succussions plash N Y
反跳痛无有液波震颤无有振水音无有
Mass N Y(position size) discription of feature liver:
carVtbe腹部包块无有(部位大小)特征描述肝未触及
touched can be touched :
subcostal cm under xipfoid process
可触及肋下厘米剑突下
discription of feature gallbladder:
can't be touched can be touched
特征描述胆囊未触及可触及
size cm tenderness N Y Murphy's sign spleen:
can't be大小厘米压痛无有Murphy征脾未触及
touched can be touched distanee from costal margin cm
可触及肋下厘米
Kideny:
can't be touched can be touched size consistency
肾未触及可触及大小硬度
tenderness mobility tenderness of ureters:
N Y (position)
压痛移动度输尿管压痛点无有（部位）
percussion:
borders of liver dull(existanee shrink obliteration )
叩诊肝浊音界(存在缩小消失)
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)
移动性浊音无有肾区叩痛无有(右左)
ausculation :
borhorygmus n ormal in creased decreased
听诊肠鸣音正常增强减弱
disappear gurgling N Y vessal bruits N Y (position)
消失气过水声无有血管杂音无有(部位)
Genitalia :
not examined normal abnormal Rectum and Anus :
生殖器未查正常异常肛门直肠
not examined no
rmal abnormal
未查正常异常
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 )
棘突压痛叩痛(部位)
Mobility :
normal restricted extremeties:
normal abnormal
移动度正常受限四肢正常异常
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(部位及特征)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
(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'ssign left(+) (-) right(+)(-) others
Kernig征左(+ )(・)右(+ )(-)其他
Labora tory findi ngs
实验室及器械检查结果
(The imports nt laboratory exami nation .X・ ray ・ ECG and other result areincluded)(重要的化验、X线、心电图及其他有关化验)Nunber of X-ray X线片号
Abstract
病历摘要
Diag no sis(impressio ns)
入院诊断
Recorder
病史记录者
Exami ner
并使审阅者
Date of record
记录日期。