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 Race

姓名年龄性别婚否xx民族

Occupation Date of admission Informant 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

Immunizations Allergies:

N Y clinical manifestation

预防接种xxxxxx无有临床表现

allergen:

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√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 disturbance insomnia disturbance of consciousness

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

alcohol intake 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:

N Y