住院病历中英文对照.doc

POMR (Problem-Oriented Medical Records)Biographical data:Name Age Sex Marital status Nativity Race Occupation Date of admission Informant History Chief complaintHistory of present illnessPast historyPrevious health status: well ordinary bad Infectious diseases Immunizations Allergies: N Y clinical manifestation allergen: Trauma: Surgery: 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)()Respiratory system:Sore throat chronic cough sputum hemoptysis wheezing dyspnea chest pain cadiovascular system:Palpitation dyspnea on exertion hemoptysis syncope edema of lower limbs precordial pain hypertention Digestive system:Anorexia sour regurgitation belching nausea vomitting abdominal distention abdominal pain constipation diarrhea hematemesis melena hematochezia jaundice Urinary system:Lumbago frequent micturition urgent micturition urodynia dysuria hematuria nocturia polyuria oliguria facial edema Hematopoietic systemFatigue dizziness blurred vision gingival bleedig subcutaneous hemorrhage ostealgia epistaxis Metabolic and endocrine system:Excessive appetite anorexia sweats cold intolerance polydipsia tremor hands change of character obvious obesity emaciation hirsutism hair losing pigmentation chang of sexual function amenorrhea Musculoskeletal systemFloating arthralgia arthraliga swelling of joints deformiteies of jionts myalgia atrophy of muscle Nervous systemDizziness headache vertigo syncope degeneration of memory visual disturbance insomnia disturbance of consciousness tremor spasm paralysis paresthesia Personal history:Birthplace Occupation sexual history smoking N Y about years average pieces per day ceased for years / alcohol intake N occasional frequent about years average ml per day others ml/ Marital history:Marrying age companions state of health Menorrhea and Childbearing:Menarche age cycle lasting for days date of last period (age of menopause)Amount of flow: little normal large menstrual pain: N Y cycle: regular irregular pregnancy times natural labor times abortions times premature delivery times stillbirths times difficult labor and its condition Familly history (pay attention to the congenital diseases andcommunicable diseases and communicable dieases related to the paitent Father: still alive illness died cause of deaths mother: still alive illness died cause of death siblings: others: Physical examinationVital signs:Temperaturepulse /min/respiration /min/B.P mmHgGeneral Appearance:Development:ortho-sthenic typeasthenic typesthenic typenutrition:wellfairlypoorcachexiaFacial features:normalacutechronicothersExpression:naturalpainfulanxiousdreadfulindifferentPosition: active semi-recumbent others Gait: normal abnormal Conciousness: aware somnolence confusion stupor coma delirium coppperatio; well badly Mucocutaneous color: normal red pale cyaosis stainted yellow pigmentation lesions:N Y (type and distribution) Subcutaneous hemorrhange: N Y(type and distribution) Hair: normal reduced edema: N Y(position and degree) Hepatic palm: N Y spider angionma:N Yposition numbers others: ( ) Lymphnodes:Superficial lymph nodes: non-swelling swelling(position and characteristics) Head : cranium : size : normal large small deformity: N Y(coxycephaly squared skull deforming skull) Others: tenderness mass sunk (position) Eyes eyelid: normal edema ptosis trichiasis conjunctive : normal hyperemia edema hemrrhage eye ball: normal proptosis depression tremor motion dysfunction(left right)Sclera :normal yellow cornea : normal abnormal ( left right ) Pupils: equal roundness same size unequal left cm cmreaction to light: normal delay (left right) disappear (left right) Others:Ears: auricle :normal deformity fistula others (left right ) excretions of external auditory canal: N Y (left right feature) Tenderness of mastoid : N Y audation dysfunction: N Y (left right) Nose: shape : normal: abnormal ( ) other abnormalities:N Y Nosalala flap obsruction excretions nasal sinus tenderness: N Y (position ) Mouth lips :red syanosis pale herpes fissure mucosa :normal abnormal ( pale petechia) Opening of parotid gland duct: normal abnormal (swelling suppurative excretions)Tongue:normal abnormal (coverings tremor leaning to left or right) Gums: normal swelling pus overflow hemorrhage pigments lead line tooth:regular edentulous carious teeth | |Tonsils: pharynx: voice: normal hoarse Neck:resistence:N Y carotid artery pulsation: normal increased decreased (left right) jugular vein:normal distention high distention trachea:middle deviation to (left right) Hepatojugular reflux:(-) (+) thyroid: normal swelling degree -+ Symmetry Dominance in one side: spreading nodular:soft hard others :N Y (tenderness tremor bruits) Chest topography:normal barrel chest pigeon chest funnel chest flat chest bulging or retraction (left right ) bulging in the precordial region tenderness of sternum Breast: normal symmetrical abnormal : left right(gynecomastia mass tenderness excretions of nipples) LungInspection : movement of respiration : normal abnormal : left right( increased decreased) Intercostal space :normal wide narrow(position) Palpation : vocal fremitus:normal abnormal :left right (increased decreased ) pluernal friction rubs: N Yposition Subcutaneous crepitus: N Y(posotion) percussion: resonance abnormal dullness flatness hyperresonance tympany Lower borders:scapular line: right intercostal space, left intercostal space Range of mobility: right cm , left cm cm cmDusculation: breath regular irregular Breath sound: normal abnormal( feature, position ) Rale: N Y ronchi: sonorous sibilant Moist rales: coarse medium fine rales crepitus Vocal conduction: normal abnormal: reduced increased(position) Plueral friction rubs: N Y (position) Heart Inspection:bulging in precordial region : N Y apex impulse: normal unseen increased diffusing position: normal deviation ( the distance from midclavicular line cm) Other precordial pulsations: N Y (position) Palpation:apex impulse:normal increased thrust unclear thrills :N Y (position period) percardial friction rubs:N Y Percussion:relative cardiac outline: normal shrink extant (right left ) Ausculation: heart rate bpm/min rhythm(regular irregular / absolutly irrgelar) heart sound:S1normal increased decreased S1 split S2 normal increased decreased split S2 S3 N Y S4 N Y A2 P2S3 S4 A2 P2Extra heart sound N gallop (diastolic presystotic summalion gallop) opening snap others murmurs: N Y (degree conduction) Pericardial friction rubs N Y Peripheral vessals: normal pistal shot of big arteries Duroziezs sign water hammer pulse capillary pulsation pulse deficit paradoxical pulse pulsus alternans other AbdomanInspection: shape normal distention frog abdomen( size cm) scaphoid apical abdomen gastral pattern intestinal pattern peristalsis abdominal respiration:existance disappear umbilicus: normal protruding excretions others: N Y(venous distention of abdoman purple striae surgical scars hernia) Palpation: soft muscle tension position tenderness N Y rebound tenderness N Y fluidthtill N Y succussions plash N Y Mass N Y(position size) discription of feature liver:cant be touched can be touched :subcostal cm under xipfoid process discription of feature gallbladder: cant be touched can be touched size cm tenderness N Y Murphys sign spleen: cant be Murphy touched can be touched distance from costal margin cm Kideny:cant be touched can be touched size consistency tenderness mobility tenderness of ureters: N Y (position) percussion: borders of liver dull(existance shrink obliteration ) Upper borders of liver on right midclavicular line intercostal space shifting dullness N Y tenderness in renal region N Y (right left ) ausculation : borhorygmus normal increased decreased disappear gurgling N Y vessal bruits N Y (position) Genitalia :not examined normal abnormal Rectum and Anus : not examined normal abnormal Spine and ExtremitiesSpine : normal deformities (lateral anterior posteri