表格式住院病例中英版POMR.docx
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表格式住院病例中英版POMR.docx
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表格式住院病例中英版POMR
POMR(Problem-OrientedMedicalRecords)表格式住院病历
Biographicaldata:
一般项目:
NameAgeSexMaritalstatusNativityRace
姓名年龄性别婚否籍贯民族
OccupationDateofadmissionInformantHistory
职业入院日期病史叙述者病史
Chiefcomplaint
主诉
Historyofpresentillness
现病史
Pasthistory
既往史:
Previoushealthstatus:
wellordinarybadInfectiousdiseases
平素健康状况:
良好一般较差传染病史
ImmunizationsAllergies:
NYclinicalmanifestation
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
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
communicablediseasesandcommunicablediseasesrelatedtothepaitent
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:
normalabnormal(leftright)
巩膜无黄染有黄染角膜正常异常(左右)
Pupils:
equalroundnesssamesizeunequalleftcm
瞳孔等圆等大不等左cm
reactiontolight:
normaldelay(leftright)disappear(leftright)对光反射正常迟钝(左右)消失(左右)
Others:
其他
Ears:
auricle:
normaldeformityfistulaothers(leftright)
耳耳廓正常畸形瘘管其他(左右)
excretionsofexternalauditorycanal:
NY(leftrightfeature)
外耳道分泌物无有(左右性质)
Tendernessofmastoid:
NYaudationdysfunction:
NY(leftright)
乳突压痛无有听力粗试障碍无有(左右)
Nose:
shape:
normal:
abnormal()otherabnormalities:
NY
鼻外形正常异常()其他异常无有
Nosalaflapobstructionexcretionsnasalsinustenderness:
鼻翼扇动鼻塞分泌物鼻旁窦压痛
NY(position)
无有(部位)
Mouthlips:
redsyanosispaleherpesfissuremucosa:
normal
口唇红润发绀苍白疱疹皲裂粘膜正常
abnormal(palepetechia)
异常(苍白出血点)
Openingofparotidglandduct:
normalabnormal(swelling
腮腺导管开口正常异常(肿胀
suppurativeexcretions)
脓性分泌物)
Tongue:
normalabnormal(coveringstremorleaningtoleftorright)
舌正常异常(舌苔伸舌震颤向左、向右偏斜)
Gums:
normalswellingpusoverflowhemorrhagepigments
牙龈正常肿胀溢脓出血色素沉着
leadlinetooth:
regularedentulouscariousteeth
铅线牙列齐缺牙—|—龋齿—|—
Tonsils:
pharynx:
voice:
normalhoarse
扁桃体咽声音正常嘶哑
Neck:
resistance:
NYcarotidarterypulsation:
normalincreased
颈部抵抗感无有颈动脉搏动正常增强
decreased(leftright)jugularvein:
normaldistention
减弱(左右)颈静脉正常充盈
highdistentiontrachea:
middledeviationto(leftright)
怒张气管正中偏移(向左向右)
Hepatojugularreflux:
(-)(+)thyroid:
normalswellingdegree
肝颈静脉回流征:
(-)(+)甲状腺正常肿大度
Symmetry对称
Dominanceinoneside:
spreadingnodular:
softhardothers:
NY
侧为主弥漫性结节性质软质硬其他无有
(tendernesstremorbruits)
(压痛震颤血管杂音)
Chesttopography:
normalbarrelchestpigeonchestfunnelchest
胸部胸廓正常桶状胸鸡胸漏斗胸
flatchestbulgingorretraction(leftright)
扁平胸膨隆或凹陷(左右)
bulgingintheprecordialregiontendernessofsternum
心前区膨隆胸骨压痛
Breast:
normalsymmetricalabnormal:
leftright(gynecomastia
乳房正常对称异常左右(男乳女化
masstendernessexcretionsofnipples)
包块压痛乳头分泌物)
Lung
肺
Inspection:
movementofrespiration:
normalabnormal:
left
视诊呼吸运动正常异常左
right(increaseddecreased)
右(增强减弱)
Intercostalspace:
normalwidenarrow(position)
肋间隙正常增宽变窄(部位)
Palpation:
vocalfremitus:
normalabnormal:
leftright(increased
触诊:
语颤正常异常左右(增强
decreased)pluernalfrictionrubs:
NY(position)
减弱胸膜摩擦感:
无有(部位)
Subcutaneouscrepitus:
NY(posotion)percussion:
resonance
皮下捻发感无有(部位)叩诊正常清音
abnormaldullnessflatnesshyperresonancetympany
异常叩诊音浊音实音过清音鼓音
Lowerborders:
scapularline:
rightintercostalspace,left
肺下界肩胛线右肋间左
intercostalspaceRangeofmobility:
rightcm,leftcm
肋间移动度右cm,左cm
Dusculation:
breathregularirregular
听诊呼吸规整不规整
Breathsound:
normalabnormal(feature,position)
呼吸音正常异常(性质,部位描写)
Rale:
NY:
ronchi:
sonoroussibilant
啰音:
无有:
干性鼾音哨笛音
Moistrales:
coarsemediumfineralescrepitus
湿性大中小水泡音捻发音
Vocalconduction:
normalabnormal:
reducedincreased(position)
语音传导正常异常减弱增强(部位)
Plueralfrictionrubs:
NY(position)
胸膜摩擦音无有(部位)
Heart心
Inspection:
bulginginprecordialregion:
NYapeximpulse:
视诊心前区隆起无有心尖搏动
normalunseenincreaseddiffusingposition:
normal
正常未见增强弥散心尖搏动位置正常
deviation(thedistancefrommidclavicularlinecm)
移动(距左锁骨中线内外厘米)
Otherprecordialpulsations:
NY(position)
其他部位搏动无有(部位)
Palpation:
apeximpulse:
normalincreasedthrustunclear
触诊心尖搏动正常增强抬举感触不清
thrills:
NY(positionperiod)percardialfrictionrubs:
NY
震颤无有(部位时期)心包摩擦感无有
Percussion:
relativecardiacoutline:
normalshrinkextant(rightleft)
叩诊相对浊音界正常缩小扩大(右左)
Ausculation:
heartratebpm/minrhythm(regularirregular
听诊心率次/分心律(齐不齐)
absolutlyirrgelar)heartsound:
S1normalincreaseddecreased
绝对不齐心音S1正常增强减弱
splitS2normalincreaseddecreasedsplit
分裂S2正常增强减弱分裂
S3NYS4NYA2P2
S3无有S4无有A2P2
ExtraheartsoundNgallop(diastolicpresystoticsummalion
额外心音无奔马律(舒张期收缩前期重叠
gallop)openingsnapothersmurmurs:
NY(degreeconduction)
开瓣音其他杂音无有(图示并描述传导)
PericardialfrictionrubsNY
心包摩擦音无有
Peripheralvessals:
normalpistalshotofbigarteries
周围血管无异常血管征大血管枪击音
Duroziez’ssignwaterhammerpulsecapillarypulsation
二重杂音水冲脉毛细血管搏动
pulsedeficitparadoxicalpulsepulsusalternansother
脉搏短绌奇脉交替脉其他
Abdoman
腹部
Inspection:
shapenormaldistentionfrogabdomen(sizecm)
视诊外形正常膨隆蛙腹(腹围厘米)
scaphoidapicalabdomengastralpatternintestinalpattern
舟腹尖腹胃型肠型
peristalsisabdominalrespiration:
existancedisappearumbilicus:
蠕动波腹式呼吸存在消失脐
normalprotrudingexcretionsothers:
NY(venousdistentionof
正常凸出分泌物其他异常无有(腹壁静脉曲张
abdomanpurplestriaesurgicalscarshernia)
条纹手术疤痕疝)
Palpation:
softmuscletensionpositiontendernessN
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