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ID:10083136
大小:31.83 KB
页数:8页
时间:2018-05-24
《住院病历中英文对照》由会员上传分享,免费在线阅读,更多相关内容在行业资料-天天文库。
1、1.POMR(Problem-OrientedMedicalRecords)表格式住院病历2.Biographicaldata:一般项目:3.NameAgeSexMaritalstatusNativityRace姓名年龄性别婚否籍贯民族4.OccupationDateofadmissionInformantHistory职业入院日期病史叙述者病史5.Chiefcomplaint主诉6.Historyofpresentillness现病史Pasthistory既往史:7.Previoushealthstatus:wellordin
2、arybadInfectiousdiseases平素健康状况:良好一般较差传染病史8.ImmunizationsAllergies:NYclinicalmanifestation预防接种史过敏史无有临床表现9.allergen:Trauma:Surgery:过敏原外伤史手术史10.Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpostive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandth
3、erapy)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)11.Respiratorysystem:呼吸系统12.Sorethroatchroniccoughsputumhemoptysiswheezing 咽痛慢性咳嗽咳痰咯血哮喘13.dyspneachestpain呼吸困难胸痛14.cadiovascularsystem:循环系统15.Palpitationdyspneaonexertionhemoptysissyncope心悸活动后气促咯血晕厥 16.edemaoflowerlimbspreco
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10、ligaswellingofjoints 游走性关节痛关节痛关节红肿deformiteiesofjiontsmyalgiaatrophyofmuscle !f7T4%p;e.^;n关节变形肌肉痛肌肉萎缩 Nervoussystem0J8Y(x1f,O1u/t-
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