表格式住院病例中英版POMR精校版

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(payattentiontothecongenitaldiseasesandcommunicablediseasesandcommunicabledieasesrelatedtothepaitent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mmHgGeneralAppearance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cmreactiontolight: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Nosalalaflapobsructionexcretionsnasalsinustenderness: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:resistence:NYcarotidarterypulsation:normalincreased颈部抵抗感