医学住院病历英文

住院病历的英汉对照 分享 首次分享者:燕子已被分享1次评论(0)复制链接分享转载举报 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 姓名年龄性别婚否籍贯民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 Chief complaint 主诉 History of present illness 现病史 Past history 既往史: Previous health status: well ordinary bad Infectious diseases 平素健康状况:良好一般较差传染病史 Immunizations Allergies: N Y clinical manifestation 预防接种史过敏史无有临床表现 allergen: Trauma: Surgery: 过敏原外伤史手术史 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 食欲亢进食欲减退多汗畏寒 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 消瘦多毛毛发脱落色素沉着 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: 个人史 Birthplace Occupation sexual history smoking N Y 出生地职业冶游史吸烟无有 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: 婚姻史: Marrying age companion’s state of health 结婚年龄配偶健康状况 Menorrhea and Childbearing: 月经及生育史 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 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 communicable diseases and communicable dieases related to the paitent 家族史(注意与患者现病有关的遗传病和传染性疾病) 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 Appearance一般状况: Development发育: ortho-sthenic type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 Position: active semi-recumbent others 体位:自主半卧位其他 Gait: normal abnormal 步态正常不正常 Conciousness: aware somnolence confusion stupor coma 神志清楚嗜睡模糊昏睡昏迷 delirium coppperatio; well badly 谵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绀 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(position numbers ) others: 肝掌无有蜘蛛痣无有(部位数目) 其他 Lymphnodes: 淋巴结 Superficial lymph nodes: non-swelling swelling(position and characteristics) 全身淋巴结肿大无肿大肿大(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 瞳孔等圆等大不等左 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 ) 耳耳廓正常畸形瘘管其他(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 : normal: abnormal ( ) other abnormalities:N Y 鼻外形正常异常()其他异常无有 Nosalala 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 :normal 口唇红润发绀苍白疱疹皲裂粘膜正常 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—|—龋齿—|— Tonsils: pharynx: voice: normal hoarse 扁桃体咽声音正常嘶哑 Neck:resistence:N Y carotid artery pulsation: normal increased 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) 怒张气管正中偏移(向左向右) Hepatojugular reflux:(-) (+) thyroid: normal swelling degree 肝颈静脉回流征:(-)(+)甲状腺正常肿大度 Symmetry 对称 Dominance in one side: spreading nodular:soft hard others :N Y 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 : left right(gynecomastia 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( increased 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: resonance 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 Dusculation: 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: N Y :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 Inspection:bulging in precordial region : N Y apex impulse: 视诊心前区隆起无有心尖搏动 normal unseen increased diffusing position: normal 正常未见增强弥散心尖搏动位置正常 deviation ( the distance 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:N Y 震颤无有(部位时期)心包摩擦感无有 Percussion:relative cardiac outline: normal shrink extant (right left ) 叩诊相对浊音界正常缩小扩大(右左) Ausculation: heart rate bpm/min rhythm(regular irregular 听诊心率次/分心律(齐不齐) absolutly irrgelar) heart sound:S1 normal increased decreased 绝对不齐心音 S1 正常增强减弱 split S2 normal increased 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 额外心音无奔马律(舒张期收缩前期重叠 gallop) opening snap others murmurs: 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 alternans other 脉搏短绌奇脉交替脉其他 Abdoman 腹部 Inspection: 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:existance 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 Y fluidthtill 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:can’t be 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 distance 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(existance 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 normal increased 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 normal 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’s sign left(+)(-)right(+)(-) others Kernig征左(+)(-)右(+)(-)其他 Laboratory findings 实验室及器械检查结果 (The important laboratory examination .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 Diagnosis(impressions) 入院诊断 Recorder 病史记录者 Examiner 并使审阅者 Date of record 记录日期