表格式住院病例中英版pomr

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1、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:wellordinarybadInfectiousdi

2、seases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

3、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

4、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dysuriahematurianocturiapolyu

5、riaoliguriafacialedema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polydipsiatremor

6、handschangeofcharacterobviousobesity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

7、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aboutyea

8、rsaveragepiecesperdayceasedforyears约年平均支/日戒烟年alcoholintakeNoccasionalfrequentaboutyears嗜酒无偶有经常约为年averag