住院病历中英文对照Inpatient medical records in English and Chinese.docx
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住院病历中英文对照Inpatient medical records in English and Chinese.docx
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住院病历中英文对照InpatientmedicalrecordsinEnglishandChinese
住院病历中英文对照(InpatientmedicalrecordsinEnglishandChinese)
住院病历中英文对照(InpatientmedicalrecordsinEnglishand
Chinese)
WiththestrengtheningofcommunicationbetweenChinaandforeigncountries,specializedEnglishisbecomingmoreandmoreimportanttohospitals!
Tooksometimetosortoutthe"inpatientmedicalrecordsofEnglishandChinese"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
Edema,of,lower,limbs,precordial,pain,hypertention
Edemaoflowerextremities,precordialpain,hypertension
Digestivesystem:
Digestivesystem
Anorexia,sour,regurgitation,belching,nausea,vomitting
Anorexiasourregurgitationbelchingnauseaandvomiting
Abdominal,distention,abdominal,pain,constipation,
diarrhea
Abdominaldistension,abdominalpain,constipation,diarrhea
Hematemesismelenahematocheziajaundice
Hematemesismelenahematocheziajaundice
Urinarysystem:
urinarysystem
Lumbago,frequent,micturition,urgent,micturition,urodynia
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,significantobesity
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,rednessandswellingofthe
joints
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
MenorrheaandChildbearing:
Menstrualandreproductivehistory
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:
normalabnormal
Normalgait;abnormal
Conciousness:
aware,somnolence,confusion,stupor,coma
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,ball:
normal,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:
正常畸形瘘管其他(左右)
耳耳廓正常畸形瘘管其他(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:
NY(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苍白疱疹皲裂粘膜:
正常
口唇红润发绀苍白疱疹皲裂粘膜正常
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:
定期牙龋坏牙齿
铅线牙列齐缺牙-|-龋齿-|—
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(-)(+):
正常甲状腺肿胀的程度
肝颈静脉回流征:
(-)(+)甲状腺正常肿大度
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:
NY(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
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