住院病历中英文对照.docx
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住院病历中英文对照
住院病历中英文对照(Inpatientmedicalrecordsin
EnglishandChinese)
住院病历中英文对照(InpatientmedicalrecordsinEnglishand
Chinese)
WiththestrengtheningofcommunicationbetweenChinaandforeigncountries,specializedEnglishisbecomingmoreandmoreimportanttohospitals!
TooksometimetosortouttheinpatientmedicalrecordsofEnglishandChinese"format,sentupandsharewithyou,andIhopetohelppeoplewhocanuseit!
POMR(Problem-Oriented,Medical,Records)tabularformatinpatientmedicalrecords
Biographicaldata:
Generalproject:
Name,Age,Sex,Marital,status,Nativity,Race
Nameagegendermaritalstatus,ethnicorigin
Occupation,Date,of,admission,Informant,History
Occupationaldateofadmission,history,historyofthenarrator
Chiefcomplaint
Chiefcomplaint
Historyofpresentillness
HistoryofPresentIllness
Pasthistory
Pasthistory:
Previous,health,status:
well,ordinary,bad,Infectious,diseases
Previoushealthstatus:
goodgeneralbadinfectiousdiseases
Immunizations,Allergies:
N,Y,clinical,manifestation
Thevaccinationhistoryofallergyhistorywithclinicalmanifestations
Allergen:
Trauma:
Surgery:
Allergen,historyoftrauma,historyofoperation
Review,of,systems:
(Tick,if,positive,cross,if,negative・,If,postive,you,should,out,write,down,,your,,disease,therapy,history,and,and,diagnose,brief,course,of,etc・)
Systematicreview:
(aplaywithoutmeyour*positivehistoryshouldfillinthetimeofonsetinthefollowingspaceandbrieflyaftertreatment)
Respiratorysystem:
Respiratorysystem
Sore,throat,chronic,cough,sputum,hemoptysis,wheezing
Chronicsorethroatcoughasthmasputumhemoptysis
Dyspneachestpain
Dyspnea,chestpain
Cadiovascularsystem:
circulatorysystem
Palpitation,dyspnea,on,exertion,hemoptysis,syncope
Palpitationdyspneaonexertionhemoptysissyncope
Edemaoflowerextremities,precordialpain,hypertension
Digestivesystem:
Digestivesystem
Anorexia,sour,regurgitation,belching,nausea,vomitting
Anorexiasourregurgitationbelchingnauseaandvomiting
Abdominal,distention,abdominal,pain,constipation,diarrhea
Urinarysystem:
urinarysystem
Lumbagofrequentmicturition
Dysuria,hematuria,nocturia,polyuria,oliguria,facial,edema
Dysuriahematurianocturiaurinaryoliguriafacialedema
Hematopoieticsystem
Hemopoieticsystem
Fatigue,dizziness,blurred,vision,gingival,bleedig
Lackofstrength,dizziness,gumbleeding
Subcutaneoushemorrhageostealgiaepistaxis
Subcutaneoushemorrhageostealgiaepistaxis
Metabolicandendocrinesystem:
Metabolismandendocrinesystem
Excessive,appetite,anorexia,sweats,cold,intolerance
Hyperthyroidismappetiteanorexiahyperhidrosischills
Polydipsia,
tremor,hands,change,of,character,obvious,obesity
Polydipsia,
tremorofbothhands,personalitychanges,significant
obesity
Emaciation,
hirsutism,hair,losing,pigmentation
Emaciation,
hirsutism,hairloss,pigmentation
Chang,of,sexual,function,amenorrhea
Amenorrheaduetosexualdysfunction
Musculoskeletalsystem
Musculoskeletalsystem
Floating,arthralgia,arthraliga,swelling,of,joints
Migratoryarthralgia,arthralgia,rednessandswellingofthejoints
Deformiteies,of,jionts,myalgia,atrophy,of,muscle
Jointdeformation,musclepain,muscleatrophy
Nervoussystem
nervoussystem
Dizziness,headache,
vertigo,syncope,degeneration,of,memory
Dizziness,headache,
dizziness,syncope,memoryloss
Visual,disturbance,
insomnia,disturbance,of,consciousness
Visualimpairment,insomnia,disturbanceofconsciousness
Tremorspasmparalysisparesthesia
Convulsions,convulsions,paralysis,paresthesia
Personalhistory:
Personalhistory
Birthplace,Occupation,sexual,history,smoking,N,Y
Bornwithoutasmokinghistoryofoccupationexcursion
About,years,average,pieces,per,day,ceased,for,years
Aboutanaverageyear/dayforquittingsmoking
Alcohol,intake,N,occasional,frequent,about,years
Alcoholicdrinksareoccasionallyfrequentforaboutanyear
Average,ML,per,day,others
Averageml/days,others
Maritalhistory:
Marriagehistory:
Marrying,age,companion,s,state,,of,health
Marriageage,spouse,healthstatus
Menorrhea
andChildbearing:
Menstrual
andreproductivehistory
Menarche,
age,cycle,lasting,for,days,date,of,period,last
Menarche;
durationofeach;lastmenstrualperiod
(age,of,
menopause)
ageofmenopause
Amount,of,flow:
little,normal,large,menstrual,pain:
Y,N
Lessmenstrualvolume,morenormalpain,nodysmenorrhea
Cycle:
regular,irregular,pregnancy,times,natural,labor
Irregularmenstrualperiod,pregnancy,spontaneousdelivery
Times,abortions,times,premature,delivery,times
Fetalabortion,fetalprematurebirth,fetus
Stillbirths,times,difficult,labor,and,its,condition
Stillbirth,dystocia,andcondition
Famillyhistory(pay,attention,to,the,congenital,diseases,and)
Communicable,diseases,and,communicable,dieases,related,to,the,paitent
Familyhistory(attentiontoinheriteddiseasesandinfectiousdiseasesassociatedwiththepatient'sdisease)
Father:
still,alive,illness,died,cause,of,deaths,mother:
Father:
still,alive,illness,died,cause,of,death,
siblings:
others:
Living,illness,latedeath,siblings,children,others
Physicalexaminationphysicalexamination
VitalsignsofVitalandsigns:
Temperaturebodytemperature
Pulsepulse/min/min
Respirationrespiratory/min/min
B.PbloodpressuremmHg
GeneralAppearancegeneralstatus:
Developmentdevelopment:
Ortho-sthenictypenormal
Asthenictypeisbad
Sthenictypesupernormal
Nutritionnutrition:
Wellgood
Fairlymedium
Poorisbad
Cachexiacachexia
Facialfeaturesface:
Normal:
normal
Acuteacute
Chronicchronic
Othersother
Expressionexpression:
Naturalknowshimself
Painfulpain
Anxiousworries
Dreadfulfear
Indifferentindifference
Position:
activesemi-recumbentothers
Posture:
autonomy,semirecumbentposition,others
Gait:
norma1abnorma1
Norma1gait;abnorma1
coma
Conciousness:
aware,somnolence,confusion,stupor,
Sanity,lethargy,coma,coma
Deliriumcoppperatio;wellbadly
Delirium,cooperation,examination,cooperation,noncooperation
Mucocutaneous,color:
normal,red,pale,cyaosis,stainted
Color:
normalredpaleskinandmucousmembranecyanosis
Yellow,pigmentation,lesions:
N,Y(type,and,distribution)
Yellowpigmentation,rash,no(typeanddistribution)
Subcutaneous,hemorrhange:
N,Y(type,and,distribution)
Thereisnosubcutaneousbleeding(typeanddistribution)
Hair:
normal,reduced,edema:
N,Y(position,and,degree)
Hairdistributionnormal,edema,loss(locationandextent)
Hepatic,palm:
N,Y,spider,angionma:
N,Y(position,numbers)others:
Thereisnospiderinthepalmoftheliver・Therearenospots
(parts,numbers)
Lymphnodes:
Lymphgland
Superficial,lymph,nodes:
non-swelling,swelling(position,and,characteristics)
Thewholebodylymphnodeenlargement,noenlargement(locationandcharacteristic)
Head:
cranium:
size:
normal,large,small,deformity:
Head,skullsize,normalsize,deformity
NY(coxycephaly,squared,skull,deforming,skull)
Thereisno(oxycephalyheadcranialdeformation)
Others:
tenderness,mass,sunk(position)
Otherabnormalities:
tenderness,lump,depression(location)
Eyes,eyelid:
normal,edema,ptosis,trichiasis,conjunctive:
Thenormaleyelidconjunctivaedemaptosistrichiasis
Normalhyperemiaedemahemrrhage
Normalcongestion,edemaandbleeding
Eye,ballnormal,proptosis,depression,tremor
Theeyeballisnormal,prominent,sunken,andtremulous
Motiondysfunction(leftright)
Dyskinesia
Sclera:
normal,yellow,cornea:
normalabnormal(leftright)
Therewerenoyellowstaining,yellowstaining,normalcornealabnormalities(leftandright)
瞳孔等圆等大不等左cm
瞳孔等圆等大不等左厘米
对光反应:
正常的延迟(左右)消失(左右)对光反射正常迟钝(左
右)消失(左右)
别人:
其他
耳:
耳廓:
正常畸形痿管其他(左右)
耳耳廓正常畸形痿管其他(左右)
外耳道分泌物:
NY(左右的特征)
外耳道分泌物无有(左右性质)
压痛乳突:
NYaudation功能障碍:
'Y(左右)
乳突压痛无有听力粗试障碍无有(左右)
鼻子:
形状:
正常异常()其他异常:
NY
鼻外形正常异常()其他异常无有
鼻翼扇动鼻塞分泌物鼻旁窦压痛:
鼻翼扇动鼻塞分泌物鼻旁窦压痛
y(位置)
无有(部位)
嘴唇:
红色syanosis苍口疱疹皴裂粘膜:
正常
口唇红润发绡苍口疱疹皴裂粘膜正常
异常(苍白出血点)
异常(苍白出血点)
腮腺导管开口正常异常(肿胀
腮腺导管开口正常异常(肿胀
化脓性分泌物)
脓性分泌物)
舌:
正常异常(伸舌震颤偏左或右)
舌正常异常(舌苔伸舌震颤向左、向右偏斜)
牙龈正常肿胀溢脓出血色素
牙龈正常肿胀溢脓出血色素沉着
铅线齿:
定期牙翻坏牙齿
铅线牙列齐缺牙-丨-轄齿-I—
扁桃腺:
咽:
声音:
正常嘶哑
扁桃体咽声音正常嘶哑
颈部:
阻力:
N颈动脉搏动正常增加
颈部抵抗感无有颈动脉搏动正常增强
降低(左右):
正常颈静脉扩张
减弱(左右)颈静脉正常充盈
怒张气管正中偏移(左右)
怒张气管正中偏移(向左向右)
肝颈静脉回流征(-)(+):
正常屮状腺肿胀的程度
肝颈静脉回流征:
(-)(+)中状腺正常肿大度
对称对称
在一侧的优势:
传播性:
软硬其他:
NY
侧为主弥漫性结节性质软质硬其他无有
(压痛震颤杂音)
(压痛震颤血管杂音)
地形:
胸部正常桶状胸鸡胸漏斗胸
胸部胸廓正常桶状胸鸡胸漏斗胸
扁平胸膨隆或凹陷(左右)
扁平胸膨隆或凹陷(左右)
在心前区膨隆胸骨压痛
心前区膨隆胸骨压痛
乳房:
正常对称:
左右(男性乳房发育异常
乳房正常对称异常左右(男乳女化
包块压痛乳头分泌物)
包块压痛乳头分泌物)
肺
肺
检查:
呼吸运动:
正常异常左
视诊呼吸运动正常异常左右(增加减少)右(增强减弱)肋间隙正常宽(位置)肋间隙正常增宽变窄(部位)触诊:
语颤:
正常异常左右(增加触诊:
语颤正常异常左右(增强减少)pluernal摩擦音、Y(位置)减弱胸膜摩擦感:
无有(部位)皮下气肿:
NY(位置)打击乐:
共振皮下捻发感无有(部位)叩诊正常清音异常浊音度过清音鼓音异常叩诊音浊音实音过清音鼓音下边界:
肩胛线:
右肋间左肺下界肩胛线右肋间左肋间移动度右左厘米厘米,肋间移动度右厘米,左厘米dusculation:
呼吸不规则听诊呼吸规整不规整呼吸音:
正常异常(特征、位置)呼吸音正常异常(性质,部位描写)音:
NY:
龙基:
响亮的嘶嘶啰音:
无有:
干性鼾音哨笛音湿罗音:
粗中细湿啰音捻发音湿性大中小水泡音捻发音
语音传导正常异常减少增加(位置)语音传导正常异常减弱增强(部位)胸膜摩擦音:
NY(位置)胸膜摩擦音无有(部位)心心
检查:
心前区隆起:
NY心尖搏动:
视诊心前区隆起无有心尖搏动正常未见增强扩散的位置:
正常正常未见增强弥散心尖搏动位置正常偏差(从锁骨中线厘米的距离)移动(距左锁骨中线内外厘米)其他部位搏动:
NY(位置)其他部位搏动无有(部位)
触诊:
心尖搏动:
正常增加推力不清楚触诊心尖搏动正常增强抬举感触不清刺激:
NY(心包摩擦音位置期):
ny震颤无有(部位时期)心包摩擦感无有打击乐:
相对浊音正常缩小现存的(左、右)叩诊相对浊音界正常缩小扩大(右左)听诊:
心率BPM/分钟(不规则的节奏听诊心率次/分心律(齐不齐)
绝对irrgelar)心音:
S1正常增强减弱绝对不齐心音S1正常增强减弱分裂S2正常增加,分裂减少
分裂S2正常增强减弱分裂
S3
S3S4无有无有A2P2
额外心音奔马(舒张presystoticsummalionN
额外心音无奔马律(舒张期收缩前期重叠
驰骋)开口卡其他杂音:
NY(度传导)
开瓣音其他杂音无有(图示并描述传导)
心包摩擦摩擦
心包摩擦音无有
外周血管:
大动脉正常手枪射击
周围血管无异常血管征大血管枪击音
二重杂音水冲脉、毛细血管搏动
二重杂音水冲脉毛细血管搏动
脉冲赤字奇脉交替脉等
脉搏短细奇脉交替脉其他
腹部
腹部
检验:
形状正常膨胀蛙腹(cm)
视诊外形正常膨隆蛙腹(腹圉厘米)
舟尖腹胃型肠型
舟腹尖腹胃型肠型