住院病历中英文对照.docx

1、住院病历中英文对照住院病历中英文对照(Inpatient medical records inEnglish and Chinese)住院病历中英文对照(Inpatient medical records in English andChinese)With the strengthening of communication between China and foreign countries, specialized English is becoming more and more important to hospitals! Took some time to sort out t

2、he inpatient medical records of English and Chinese format, sent up and share with you, and I hope to help people who can use it!POMR (Problem-Oriented, Medical, Records) tabular format inpatient medical recordsBiographical data：General project:Name, Age, Sex, Marital, status, Nativity, RaceName age

3、 gender marital status, ethnic originOccupation, Date, of, admission, Informant, HistoryOccupational date of admission, history, history of the narratorChief complaintChief complaintHistory of present illnessHistory of Present IllnessPast historyPast history：Previous, health, status:, well, ordinary

4、, bad, Infectious, diseasesPrevious health status: good general bad infectious diseasesImmunizations, Allergies:, N, Y, clinical, manifestationThe vaccination history of allergy history with clinical manifestationsAllergen: Trauma: Surgery:Allergen, history of trauma, history of operationReview, of,

5、 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)Systematic review： (a play without me your * positive history should fill in the time of onset in the following space and briefly

6、 after treatment)Respiratory system:Respiratory systemSore, throat, chronic, cough, sputum, hemoptysis, wheezingChronic sore throat cough asthma sputum hemoptysisDyspnea chest painDyspnea, chest painCadiovascular system:circulatory systemPalpitation, dyspnea, on, exertion, hemoptysis, syncopePalpita

7、tion dyspnea on exertion hemoptysis syncopeEdema of lower extremities, precordial pain, hypertensionDigestive system:Digestive systemAnorexia, sour, regurgitation, belching, nausea, vomittingAnorexia sour regurgitation belching nausea and vomitingAbdominal, distention, abdominal, pain, constipation,

8、 diarrheaUrinary system：urinary systemLumbago frequent micturitionDysuria, hematuria, nocturia, polyuria, oliguria, facial, edemaDysuria hematuria nocturia urinary oliguria facial edemaHematopoietic systemHemopoietic systemFatigue, dizziness, blurred, vision, gingival, bleedigLack of strength, dizzi

9、ness, gum bleedingSubcutaneous hemorrhage ostealgia epistaxisSubcutaneous hemorrhage ostealgia epistaxisMetabolic and endocrine system：Metabolism and endocrine systemExcessive, appetite, anorexia, sweats, cold, intoleranceHyperthyroidism appetite anorexia hyperhidrosis chillsPolydipsia,tremor, hands

10、, change, of, character, obvious, obesityPolydipsia,tremor of both hands, personality changes, significantobesityEmaciation,hirsutism, hair, losing, pigmentationEmaciation,hirsutism, hair loss, pigmentationChang, of, sexual, function, amenorrheaAmenorrhea due to sexual dysfunctionMusculoskeletal sys

11、temMusculoskeletal systemFloating, arthralgia, arthraliga, swelling, of, jointsMigratory arthralgia, arthralgia, redness and swelling of the jointsDeformiteies, of, jionts, myalgia, atrophy, of, muscleJoint deformation, muscle pain, muscle atrophyNervous systemnervous systemDizziness, headache,verti

12、go, syncope, degeneration, of, memoryDizziness, headache,dizziness, syncope, memory lossVisual, disturbance,insomnia, disturbance, of, consciousnessVisual impairment, insomnia, disturbance of consciousnessTremor spasm paralysis paresthesiaConvulsions, convulsions, paralysis, paresthesiaPersonal hist

13、ory:Personal historyBirthplace, Occupation, sexual, history, smoking, N, YBorn without a smoking history of occupation excursionAbout, years, average, pieces, per, day, ceased, for, yearsAbout an average year / day for quitting smokingAlcohol, intake, N, occasional, frequent, about, yearsAlcoholic d

14、rinks are occasionally frequent for about an yearAverage, ML, per, day, othersAverage ml/ days, othersMarital history:Marriage history:Marrying, age, companion, s, state, of, healthMarriage age, spouse, health statusMenorrheaand Childbearing：Menstrualand reproductive historyMenarche,age, cycle, last

15、ing, for, days, date, of, period, lastMenarche;duration of each; last menstrual period(age, of,menopause)age of menopauseAmount, of, flow:, little, normal, large, menstrual, pain:, Y, NLess menstrual volume, more normal pain, no dysmenorrheaCycle:, regular, irregular, pregnancy, times, natural, labo

16、rIrregular menstrual period, pregnancy, spontaneous deliveryTimes, abortions, times, premature, delivery, timesFetal abortion, fetal premature birth, fetusStillbirths, times, difficult, labor, and, its, conditionStillbirth, dystocia, and conditionFamilly history (pay, attention, to, the, congenital,

17、 diseases, and)Communicable, diseases, and, communicable, dieases, related, to, the, paitentFamily history (attention to inherited diseases and infectious diseases associated with the patients disease)Father:, still, alive, illness, died, cause, of, deaths, mother:Father: still, alive, illness, died

18、, cause, of, death,siblings：, others：Living, illness, late death, siblings, children, othersPhysical examination physical examinationVital signs of Vital and signs:Temperature body temperaturePulse pulse /min / minRespiration respiratory /min / minB. P blood pressure mmHgGeneral Appearance general s

19、tatus:Development development:Ortho-sthenic type normalAsthenic type is badSthenic type supernormalNutrition nutrition:Well goodFairly mediumPoor is badCachexia cachexiaFacial features face:Normal: normalAcute acuteChronic chronicOthers otherExpression expression:Natural knows himselfPainful painAnx

20、ious worriesDreadful fearIndifferent indifferencePosition: active semi-recumbent othersPosture: autonomy, semi recumbent position, othersGait: norma1 abnorma1Norma1 gait; abnorma1comaConciousness:, aware, somnolence, confusion, stupor,Sanity, lethargy, coma, comaDelirium coppperatio; well badlyDelir

21、ium, cooperation, examination, cooperation, non cooperationMucocutaneous, color:, normal, red, pale, cyaosis, staintedColor: normal red pale skin and mucous membrane cyanosisYellow, pigmentation, lesions:N, Y (type, and, distribution)Yellow pigmentation, rash, no (type and distribution)Subcutaneous,

22、 hemorrhange:, N, Y (type, and, distribution)There is no subcutaneous bleeding (type and distribution)Hair:, normal, reduced, edema:, N, Y (position, and, degree)Hair distribution normal, edema, loss (location and extent)Hepatic, palm:, N, Y, spider, angionma:N, Y (position, numbers) others:There is

23、 no spider in the palm of the liver There are no spots(parts, numbers)Lymphnodes:Lymph glandSuperficial, lymph, nodes:, non-swelling, swelling (position, and, characteristics)The whole body lymph node enlargement, no enlargement (location and characteristic)Head: cranium: size: normal, large, small,

24、 deformity:Head, skull size, normal size, deformityN Y (coxycephaly, squared, skull, deforming, skull)There is no (oxycephaly head cranial deformation)Others:, tenderness, mass, sunk (position)Other abnormalities: tenderness, lump, depression (location)Eyes, eyelid:, normal, edema, ptosis, trichiasi

25、s, conjunctive:The normal eyelid conjunctiva edema ptosis trichiasisNormal hyperemia edema hemrrhageNormal congestion, edema and bleedingEye, ballnormal, proptosis, depression, tremorThe eyeball is normal, prominent, sunken, and tremulousMotion dysfunction （left right）DyskinesiaSclera: normal, yello

26、w, cornea: normal abnormal （left right）There were no yellow staining, yellow staining, normal corneal abnormalities （left and right）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:N Y（左右的特征）外耳道分泌物无有（左右性质）压痛乳突:N Y audation功能障碍： Y（左右）乳突压痛无有听力粗试障碍

27、无有（左右）鼻子:形状:正常异常（）其他异常:N Y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

28、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:N Y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

29、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:N Y （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

30、音正常异常（性质，部位描写） 音:N Y: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:N Y （位置） 胸膜摩擦音无有（部位） 心心检查:心前区隆起:N Y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:N Y（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:N Y（心包摩擦音

31、位置期）：n y 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S3S3 S4无有无有A2 P2额外心音奔马（舒张presystotic summalion N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:N Y（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