表格式住院病例中英版对照Word格式文档下载.docx
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allergen:
Trauma:
Surgery:
过敏原外伤史手术史
Reviewofsystems:
(Tickifpositive,crossoutifnegative.Ifpostive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)
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
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
消瘦多毛毛发脱落色素沉着
changofsexualfunctionamenorrhea
性功能改变闭经
Musculoskeletalsystem
肌肉骨骼系统
Floatingarthralgiaarthraligaswellingofjoints
游走性关节痛关节痛关节红肿
deformiteiesofjiontsmyalgiaatrophyofmuscle
关节变形肌肉痛肌肉萎缩
Nervoussystem
神经系统
Dizzinessheadachevertigosyncopedegenerationofmemory
头昏头痛眩晕晕厥记忆力减退
visualdisturbanceinsomniadisturbanceofconsciousness
视力障碍失眠意识障碍
tremorspasmparalysisparesthesia
颤动抽搐瘫痪感觉异常
Personalhistory:
个人史
BirthplaceOccupationsexualhistorysmokingNY
出生地职业冶游史吸烟无有
aboutyearsaveragepiecesperdayceasedforyears
约年平均支/日戒烟年
alcoholintakeNoccasionalfrequentaboutyears
嗜酒无偶有经常约为年
averagemlperdayothers
平均ml/日其他
Maritalhistory:
婚姻史:
Marryingagecompanion’sstateofhealth
结婚年龄配偶健康状况
MenorrheaandChildbearing:
月经及生育史
Menarcheagecyclelastingfordaysdateoflastperiod
初潮每次持续时间末次月经时间
(ageofmenopause)
绝经年龄
Amountofflow:
littlenormallargemenstrualpain:
NY
经量少正常多痛经无有
cycle:
regularirregularpregnancytimesnaturallabor
经期规则不规则妊娠次顺产
timesabortionstimesprematuredeliverytimes
胎流产胎早产胎
stillbirthstimesdifficultlaboranditscondition
死产胎难产及病情
Famillyhistory(payattentiontothecongenitaldiseasesand
communicablediseasesandcommunicabledieasesrelatedtothepaitent
家族史(注意与患者现病有关的遗传病和传染性疾病)
Father:
stillaliveillnessdiedcauseofdeathsmother:
父:
健在患病已故死因母stillaliveillnessdiedcauseofdeathsiblings:
others:
健在患病已故死因兄弟姐妹子女其他
Physicalexamination体格检查
Vitalsigns生命体征:
Temperature体温
pulse脉搏/min次/分
respiration呼吸/min次/分
B.P血压mmHg
GeneralAppearance一般状况:
Development发育:
ortho-sthenictype正常
asthenictype不良
sthenictype超常
nutrition营养:
well良好
fairly中等
poor不良
cachexia恶病质
Facialfeatures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
Position:
activesemi-recumbentothers
体位:
自主半卧位其他
Gait:
normalabnormal
步态正常不正常
Conciousness:
awaresomnolenceconfusionstuporcoma
神志清楚嗜睡模糊昏睡昏迷
deliriumcoppperatio;
wellbadly
谵妄配合检查合作不合作
Mucocutaneouscolor:
normalredpalecyaosisstainted
皮肤粘膜色泽无病容潮红苍白紫绀
yellowpigmentationlesions:
NY(typeanddistribution)
黄染色素沉着皮疹无有(类型及分布)
Subcutaneoushemorrhange:
NY(typeanddistribution)
皮下出血无有(类型及分布)
Hair:
normalreducededema:
NY(positionanddegree)
头发分布正常减退水肿无有(部位及程度)
Hepaticpalm:
NYspiderangionma:
NY(positionnumbers)others:
肝掌无有蜘蛛痣无有(部位数目)其他
Lymphnodes:
淋巴结
Superficiallymphnodes:
non-swellingswelling(positionandcharacteristics)
全身淋巴结肿大无肿大肿大(部位及特征)
Head:
cranium:
size:
normallargesmalldeformity:
头部头颅大小正常大小畸形
NY(coxycephalysquaredskulldeformingskull)
无有(尖颅方颅变形颅)
Others:
tendernessmasssunk(position)
其他异常:
压痛包块凹陷(部位)
Eyeseyelid:
normaledemaptosistrichiasisconjunctive:
眼睑正常水肿下垂倒睫结膜
normalhyperemiaedemahemrrhage
正常充血水肿出血
eyeball:
normalproptosisdepressiontremor
眼球正常突出凹陷震颤
motiondysfunction(leftright)
运动障碍
Sclera:
normalyellowcornea:
normalabnorm