-
POMR (Problem-Oriented Medical
Records)
表格式住院病历
Biographical data:
一般项目:
Name Age Sex Marital status
Nativity Race
姓名
年龄
性别
婚否
籍贯
民族
Occupation Date
of admission Informant History
职业
入院日期
病史叙述者
病史
Chief complaint
主诉
History of present illness
现病史
Past history
既往史:
Previous health status:
well ordinary bad Infectious diseases
平素健康状况:
良好
一般
较差
传染病史
Immunizations Allergies: N Y clinical
manifestation
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
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)
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
)
Respiratory
system:
呼吸系统
Sore throat chronic cough sputum
hemoptysis wheezing
咽痛
慢性咳嗽
咳痰
咯血
哮喘
dyspnea chest pain
呼吸困难
胸痛
cadiovascular system:
循环系统
Palpitation dyspnea on
exertion hemoptysis syncope
心悸
活动后气促
咯血
晕厥
edema of lower
limbs precordial pain hypertention
下肢水肿
心前区疼痛
高血压
Digestive system:
消化系统
Anorexia sour regurgitation
belching nausea vomitting
食欲减退
反酸
嗳气
恶心
呕吐
abdominal
distention abdominal pain constipation diarrhea
腹胀
腹痛
便秘
腹泻
hematemesis melena hematochezia
jaundice
呕血
黑便
便血
黄疸
Urinary
system:
泌尿系统
Lumbago frequent micturition urgent
micturition urodynia
腰痛
尿频
尿急
尿痛
dysuria
hematuria nocturia polyuria oliguria facial edema
排尿困难
血尿
夜尿
多尿
少尿
面部水肿
Hematopoietic system
造血系统
Fatigue
dizziness blurred vision gingival bleedig
乏力
头昏
牙龈出血
subcutaneous hemorrhage ostealgia
epistaxis
皮下出血
骨痛
鼻衄
Metabolic and endocrine system:
代谢及内分泌系统
Excessive appetite anorexia sweats cold
intolerance
食欲亢进
食欲减退
多汗
畏寒
polydipsia tremor hands change of
character obvious obesity
多饮
双手震颤
性格改变
显著肥胖
emaciation hirsutism hair losing
pigmentation
消瘦
多毛
毛发脱落
色素沉着
chang of
sexual function amenorrhea
性功能改变
闭经
Musculoskeletal system
肌肉骨骼系统
Floating
arthralgia arthraliga swelling of joints
游走性关节痛
关节痛
关节红肿
deformiteies
of jionts myalgia atrophy of muscle
关节变形
肌肉痛
肌肉萎缩
Nervous
system
神经系统
Dizziness headache vertigo syncope
degeneration of memory
头昏
头痛
眩晕
晕厥
记忆力减退
visual
disturbance insomnia disturbance of consciousness
视力障碍
失眠
意识障碍
tremor spasm
paralysis paresthesia
颤动
抽搐
瘫痪
感觉异常
Personal
history:
个人史
Birthplace Occupation sexual history
smoking N Y
出生地
职业
冶游史
吸烟
无
有
about years
average pieces per day ceased for years
约
年
平均
支
/
日
戒烟
年
alcohol intake N occasional frequent
about years
嗜酒
无
偶有
经常
约为
年
average ml per
day others
平均
ml/
日
其他
Marital
history:
婚姻史:
Marrying age companion’s state of
health
结婚年龄
配偶健康状况
Menorrhea
and Childbearing:
月经及生育史
Menarche age cycle lasting for days
date of last period
初潮
每次持续时间
末次月经时间
(age of
menopause)
绝经年龄
Amount of flow: little normal large
menstrual pain: N Y
经量
少
正常
多
痛经
无
有
cycle: regular irregular pregnancy
times natural labor
经期
规则
不规则
妊娠
次
顺产
times
abortions times premature delivery times
胎
流产
胎
早产
胎
stillbirths
times difficult labor and its condition
死产
胎
难产及病情
Familly
history (pay attention to the congenital diseases
and
communicable diseases and
communicable dieases related to the paitent
家族史
(注意与患者现病有关的遗传病和传染性疾病)
Father: still alive illness died cause
of deaths mother:
父:健在
患病
已故
死因
母
still alive illness died cause of death siblings:
others:
健在
患病
已故
死因
兄弟姐妹
子女其他
Physical
examination
体格检查
Vital signs
生命体征
:
Temperature
体温
pulse
脉搏
/min
次
/
分
respiration
呼吸
/mi
n
次
/
分
B.P
血压
mmHg
General
Appearance
一般状况
:
Development
发育
:
ortho-sthenic
type
正常
asthenic
type
不良
sthenic
type
超常
nutrition
营养
:
well
良好
fairly
中等
poor
不良
cachexia
恶病质
Facial
features
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: active semi-
recumbent others
体位:
自主
半卧位
其他
Gait: normal
abnormal
步态
正常
不正常
Conciousness: aware somnolence
confusion stupor coma
神志
清楚
嗜睡
模糊
昏睡
昏迷
delirium
coppperatio; well badly
谵妄
配合检查
合作
不合作
Mucocutaneous color: normal red pale
cyaosis stainted
皮肤粘膜
色泽
无病容
潮红
苍白
紫绀
yellow
pigmentation lesions:N Y (type and distribution)
黄染
色素沉着
皮疹
无
有(类型及分布)
Subcutaneous hemorrhange: N Y(type and
distribution)
皮下出血
无
有(类型及分布)
Hair:
normal reduced edema: N Y(position and degree)
头发分布
正常
减退
水肿
无
有(部位及程度)
Hepatic palm: N Y spider
angionma:N Y
(
position
numbers
)
others:
肝掌
无
有
蜘蛛痣
无有
(
部位
数目
)
其他
Lymphnodes:
淋巴结
Superficial
lymph nodes: non-swelling swelling(position and
characteristics)
全身淋巴结肿大
无肿大
肿大(部位及特征)
Head : cranium : size :
normal large small deformity:
头部
头颅
大小
正常
大
小
畸形
N Y(coxycephaly
squared skull deforming skull)
无
有(尖颅
方颅
变形颅
)
Others: tenderness mass sunk (position)
其他异常:压痛
包块
凹陷(部位)
Eyes eyelid: normal edema ptosis
trichiasis conjunctive :
眼睑
正常
水肿
下垂
倒睫
结膜
normal
hyperemia edema hemrrhage
正常
充血
水肿
出血
eye ball:
normal proptosis depression tremor
眼球
正常
突出
凹陷
震颤
motion
dysfunction(left right)
运动障碍
Sclera :normal yellow cornea : normal
abnormal ( left right )
巩膜
无黄染
有黄染
角膜
正常
异常
(左
右
)
Pupils: equal roundness same size
unequal left cm
瞳孔
等圆
等大
不等
左
cm
reaction to light: normal
delay (left right) disappear (left right)
对光反射
正常
迟钝(左
右)
消失
(左
右)
Others:
其他
Ears: auricle
:normal deformity fistula others (left right )
耳
耳廓
正常
畸形
瘘管
其他
(左
右)
excretions of external auditory canal:
N Y (left right feature)
外耳道分泌物
无
有(左
右
性质)
Tenderness of
mastoid : N Y audation dysfunction: N Y (left
right)
乳突压痛
无
有
听力粗试障碍
无
有(左
右)
Nose: shape : normal: abnormal ( )
other abnormalities:N Y
鼻
外形
正常
异常
(
)
其他异常
无
有
Nosalala flap obsruction excretions
nasal sinus tenderness:
鼻翼扇动
鼻塞
分泌物
鼻旁窦压痛
N Y
(position )
无
有(部位)
Mouth lips
:red syanosis pale herpes fissure mucosa :normal
口唇
红润
发绀
苍白
疱疹
皲裂
粘膜
正常
abnormal ( pale petechia)
异常
(苍白
出血点)
Opening of
parotid gland duct: normal abnormal (swelling
腮腺导管开口
正常
异常
(肿胀
suppurative
excretions)
脓性分泌物)
Tongue:normal abnormal (coverings
tremor leaning to left or right)
舌
正常
异常
(舌苔
伸舌震颤
向左、向右偏斜)
Gums:
normal swelling pus overflow hemorrhage pigments
牙龈
正常
肿胀
溢脓
出血
色素沉着
lead line
tooth:regular edentulous carious teeth
铅线
牙列
齐
缺牙
—<
/p>
|
—
龋齿
p>
—
|
—
Tonsils: pharynx: voice: normal hoarse
扁桃体
咽
声音
正常
嘶哑
Neck:resistence:N Y carotid artery
pulsation: normal increased
颈部
抵抗感
无
有
颈动脉搏动
正常
增强
decreased (left right) jugular
vein:normal distention
减弱
(
左
右
)
颈静脉
正常
充盈
high
distention trachea:middle deviation to (left
right)
怒张
气管
正中
偏移
(向左
向右)
Hepatojugular
reflux:(-) (+) thyroid: normal swelling degree
肝颈静脉回流征:
(
-
)(
+
)
< br>
甲状腺
正常
肿大
度
Symmetry
对称
Dominance in
one side: spreading nodular:soft hard others :N Y
侧为主
弥漫性
结节性
质软
质硬
其他
无
有
(tenderness tremor bruits)
(压痛
震颤
血管杂音)
Chest
topography:normal barrel chest pigeon chest funnel
chest
胸部
胸廓
正常
桶状胸
鸡胸
漏斗胸
flat chest
bulging or retraction (left right )
扁平胸
膨隆或凹陷
(左
右
)
bulging in the precordial region
tenderness of sternum
心前区膨隆
胸骨压痛
Breast:
normal symmetrical abnormal : left
right(gynecomastia
乳房
正常对称
异常
左
右(男乳女化
mass
tenderness excretions of nipples)
包块
压痛
乳头分泌物)
Lung
肺
Inspection :
movement of respiration : normal abnormal : left
视诊
呼吸运动
正常
异常
左
right(
increased decreased)
右
(增强
减弱
)
Intercostal
space :normal wide narrow(position)
肋间隙
正常
增宽
变窄(
部位
)
Palpation : vocal fremitus:normal
abnormal :left right (increased
触诊
:
语颤
正常
异常
左
右
(增强
decreased ) pluernal friction rubs: N Y
(
position
)
减弱
胸膜摩擦感:
无
有(部位)
Subcutaneous crepitus: N Y(posotion)
percussion: resonance
皮下捻发感
无
有(部位)
叩诊
正常清音
abnormal
dullness flatness hyperresonance tympany
异常叩诊音
浊音
实音
过清音
鼓音
Lower borders:scapular line: right
intercostal space, left
肺下界
肩胛线
右肋间
左
intercostal space Range of mobility:
right cm , left cm
肋间
移动度
右
cm
,
左
cm
Dusculation: breath regular
irregular
听诊
呼吸
规整
不规整
Breath sound:
normal abnormal( feature, position )
呼吸音
正常
异常
(性质,
部位描写)
Rale: N Y
:
ronchi: sonorous sibilant
啰音:无
有:
干性
鼾音
哨笛音
Moist rales: coarse medium fine rales
crepitus
湿性
大
中
小水泡音
捻发音
Vocal
conduction: normal abnormal: reduced
increased(position)
语音传导
正常
异常
减弱
增强
(部位)
Plueral
friction rubs: N Y (position)
胸膜摩擦音
无
有(部位)
Heart
心
Inspection:bulging in precordial region
: N Y apex impulse:
视诊
心前区隆起
无
有
心尖搏动
normal
unseen increased diffusing position: normal
正常
未见
增强
弥散
心尖搏动位置
正常
deviation ( the distance from
midclavicular line cm)
移动
(距左锁骨中线内外
厘米)
Other
precordial pulsations: N Y (position)
其他部位搏动
无
有(部位)
Palpation:apex impulse:normal increased
thrust unclear
触诊
心尖搏动
正常
增强
抬举感
触不清
thrills :N Y
(position period) percardial friction rubs:N Y
震颤
无
有(部位
时期
)
心包摩擦感
无
有
Percussion:relative cardiac outline:
normal shrink extant (right left )
叩诊
相对浊音界
正常
缩小
扩大(右
左
)
Ausculation:
heart rate bpm/min rhythm(regular irregular
听诊
心率
次
/
分
心律
(齐
不齐
)
absolutly irrgelar) heart sound:S1
normal increased decreased
绝对不齐
心音
S1
正常
增强
减弱
split S2
normal increased decreased split
分裂
S2
正常
增强
减弱
分裂
S3 N Y S4 N Y A2 P2
S3
无
有
S4
无
有
A2
P2
Extra heart sound N gallop
(diastolic presystotic summalion
额外心音
无
奔马律(舒张期
收缩前期
重叠
gallop)
opening snap others murmurs: N Y (degree
conduction)
开瓣音
其他
杂音
无
有(图示并描述传导)
Pericardial friction rubs N Y
心包摩擦音
无
有
Peripheral vessals: normal pistal shot
of big arteries
周围血管
无异常血管征
大血管枪击音
Duroziez’s
sign water hammer pulse capillary pulsation
二重杂音
水冲脉
毛细血管搏动
pulse
deficit paradoxical pulse pulsus alternans other
脉搏短绌
奇脉
交替脉
其他
Abdoman
腹部
Inspection:
shape normal distention frog abdomen( size cm)
视诊
外形
正常
膨隆
蛙腹
(腹围
厘米)
scaphoid
apical abdomen gastral pattern intestinal pattern
舟腹
尖腹
胃型
肠型
peristalsis abdominal
respiration:existance disappear umbilicus:
蠕动波
腹式呼吸
存在
消失
脐
normal
protruding excretions others: N Y(venous
distention of
正常凸出
分泌物
其他异常
无
有(腹壁静脉曲张
abdoman purple striae
surgical scars hernia)
条纹
手术疤痕
疝)
Palpation: soft muscle tension position
tenderness N Y
触诊
柔软
腹肌紧张
部位
压痛
无
有
rebound tenderness N Y
fluidthtill N Y succussions plash N Y
反跳痛
无
有
液波震颤
无
有
振水音
无
有
Mass N
Y(position size) discription of feature
liver:can’t be
腹部包块
无
有(部位
大小)
特征描
述
肝
未触及
touched can be
touched :subcostal cm under xipfoid process
可触及
肋下
厘米
剑突下
discription of feature gallbladder:
can’t be touched can be touched
特征描述
胆囊
未触及
可触及
size cm tenderness N Y Murphy’s sign
spleen: can’t be
大小
厘米
压痛
无
有
Murphy
征
脾
未触及
touched can be
touched distance from costal margin cm
可触及
肋下
厘米
Kideny:can’t be
touched can be touched size consistency
肾
未触及
可触及
大小
硬度
tenderness mobility tenderness of
ureters: N Y (position)
压痛
移动度
输尿管压痛点
无
有(部位)
percussion: borders of
liver dull(existance shrink obliteration )
叩诊
肝浊音界
(存在
缩小
消失
)
Upper borders
of liver on right midclavicular line intercostal
space
肝上界位于右锁骨中线
肋间
shifting dullness N Y tenderness in
renal region N Y (right left )
移动性浊音
无
有
肾区叩痛
无
有(右
左)
ausculation :
borhorygmus normal increased decreased
听诊
肠鸣音
正常
增强
减弱
disappear
gurgling N Y vessal bruits N Y (position)
消失
气过水声
无
有
血管杂音
无
有
(部位)
Genitalia :not examined normal abnormal
Rectum and Anus :
生殖器
未查
正常
异常
肛门直肠
not examined normal abnormal
未查
正常
异常
Spine and
Extremities
脊柱四肢
Spine : normal deformities
(lateral anterior posterior protruding)
脊柱
正常
畸形
(侧
前
后凸
)
Spinous process
: tenderness pain while percussed ( position )
棘突
压痛
叩痛
(部位)
Mobility : normal restricted
extremeties: normal abnormal
移动度
正常
受限
四肢
正常
异常
deformity swelling of joints joints
stiffness
畸形
关节红肿
关节强直
tenderness of muscles
atrophy of muscles
肌肉压痛
肌肉萎缩
Venous distention of lower limbs
(position and feature ) acropachy
下肢静脉曲张
(部位及特征)
杵状指
Nervus System
神经系统
Abdominal wall reflex ( normal ) muscle
tone ( normal )
腹壁反射
(正常)
肌张力
(正常)
Myodynamia ( degree ) paralysis of
limbs N Y (left right
肌力
(
级
)
肢体瘫痪
无
有(左
右
upper lower)
biceps reflex left (normal) right (normal)
上
下
)
肱二头肌反射
左(正常)
右
(正常
)
knee jerk left (normal)
right( normal) achilles
jerk left
膝健反射
左(正常)
右
(正常)
跟腱反射
左
(normal) right
( normal )
正常
右
(正常)
Hoffmann’s d
ign left (+)(-)
right(+)(-)
Hoffmann
征
左(
+
)
(-)
右(
+
)(
-
)
Babinski’s sign left(+)
(
-
)
right(+)(-)
Babinski
左(
+
)(
-
)
右(
+
)(
-
)
Kernig’s sign l
eft(+)
(
-
)
< br>right(+)(-) others
Kernig
征
左(
+
)(
-
)
右(
+
)(
-
)
其他
Laboratory findings
实验室及器械检查结果
(
The important
laboratory examination .X-ray . ECG and other
result areincluded
)
(
重要的化验、
X
线、心电图及其他有关化验
) Nunber of X-ray
X
线片号
Abstract
病历摘要
Diagnosis(impressions)
入院诊断
Recorder
病史记录者
Examiner
并使审阅者
Date of record
记录日期
第一章
病人身份
[Identification]
[Name]
姓名
[Sex]
性别
[Age]
年龄
[Occupation]
职业
[Date of
birth]
出生日期
[Marriage
(
Marital
status
)
]
婚姻
[Race]
民族
[Place of birth (Birth
place)]
籍贯
[Identification No.(code of ID card No.)]
身份证号码
[Department of work
and TEL. No.
(Unit and Business phone
No.)]
工作单位及电话
[Home
address and phone No.]
家庭住址及电话
[Post
code]
邮政编码
[Person to
notify (Correspondent) and phone No.]
联系人及电话
[Source
(Complainer;offerer;supplier;provider)
of history]
病史陈术者
[Reliability of history]
病史可
*
程试
;
[Medical security (Type of payment)]
医疗费用
[Type of admission
(Patient condition)]
住院类别(入
院时病情)
[Medical record No.]
病历号
[Clinic diagnosis]
门诊诊断
[Date of admission
(admission date)]
入院日期
[Date of record]
记录日期
1
、年龄的表示方法(以<
/p>
36
岁为例)
36
years old (y/o) Age 36 36 year-old
;The age of 36 36 years of age
2
、性别的表示方法
[Male,
♂
]
男
性
[Female,
♀
]
女性
3
、职业的表示方法
;
工人
[Worker]
;
退休工作
[Retired worker]
;
农民
[Farmer
(peasant)]
;
干部
[Leader (cadre)]
;
行政人员
[administrative
personnel (staff)]
;
职员
[staff member]
;
商
人
[Trader
(Businessman)]
教师
[Teacher]
;
学生
[Student]
;
医生
[Doctor]
;
药剂师
[Pharmacist]
;
护士
[Nurse]
;
军人
[Soldier]
;***[Policeman]
;
工程师
[Engineer]
;
技术员
[Technician]
;
家政人员
[Housekeeper]
;
家庭主妇
[Housewife]
;
营业员
[Assistant]
;
服务员
[Attendant]
;
售票员
[Conductor]
4
、
民族的表示方法
;
汉
[Han]
;
回
[Hui]
;
蒙
[Meng]
;
藏
[Tibetan]
;
朝鲜
[Korean]
;
美国人
[American]
;***
人
[Japanese]
;
英国人
[Britisher]
5
、医疗费用的表示方法
[Self pay
(Individual medical care)]
自费
[Government
insruance (Public medical care)]
公费
[Insurance]
保险
[Local insurance]
本地医保
[Non-
local in surance]
外地医保
[Labor protestion care]
劳保
6
、婚姻状况的表示方法
[Married]
已
婚
[Single
(Unmarried)]
未婚
[Diverced]
离婚
[Widow]
寡妇
[Widower]
鳏夫
7
、病史可
*
程度的
表示方法
[Reliable]
可
*
[Unreliable]
不可
* [Not
entirely]
不完全可
*
[Unobtainable]
无法获得
8
、
住址的表示方法
;[NO.3,Qing Chun Road East,Hangzhou, Zhejiang]
浙江省杭州市庆春东路
3
号
< br> [XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.]
浙江省诸暨市(县)城关
镇新东村
9
、病史陈述者的表示方法
[Patient
himself (herself)]
患者本人
[Her husband]
患者的丈
夫
[His
wife]
患者的妻子
[Patient`s
colleague]
患者的同事
[Patient`s neighbor]
患者的邻居
;
[Patient`s Kin (Mother; Son;
daughter;brother;Sister)]
患者的亲属
< br>(
父亲、母亲、儿子、女儿、兄弟、
姐妹
) [Taximan]
出租车司机
[Traffic police]
交通
***
10
、日期的表示方法
2002
年
10
月
1
日
[10-
1-2002(10/1/2002;
Oct.1,2002; ,2002)](
美国
) 20
02
年
10
月
1
日
[1-10-2002(1/10/2002; 1
Oct.,2002; 1st of Oct.,2002)]
(
英国
)
11
、住院类别的表示方法
[Emergent
(Emergency call)]
急诊
[Urgent]
危重
[Elective (General)]
一般(普通)
12
、入院时病情的表示方法
[Stable]
稳定
[Unstable]
不稳定
[Relative stable]
相对稳定
[Critical
(Imminent)]
危重
[Fair
(General)]
一般
第二
章
主诉
[Chief Complaint] 1
、主诉的表示方法:症状
+
时间(
Symptom+Time
)
症状
+for+
时间如:
[Chest pain for 2 hours]
胸痛
2
小时
;
症状
+of+
时间如:
[Nausea and vomiting of three days`
duration]
恶心呕吐
3
天
;
症状
+
时间
+in duration
如:
[Headache 1
month in duration]
头痛
1
月
;
时间
+of+
症状
< br>如:
[Two-day history of fever]
发热
2
天
2
、常见症状
[Fever]
发热
[Pain]
疼痛
[Edema]
水肿
[Mucocutaneous hemorrhage (bleeding)]
皮肤粘膜出血
[Dyspnea
(Difficuly in breathing;Respiratory
difficulty;short of breath)]
呼吸困难
[Cough and
expectoration (Sputum;Phlegm)]
咳嗽和咯痰
[Hemoptysis]
咯血
; [Cyanosis]
紫绀
[Palpitation]
心悸
[Chest
discomfort]
胸闷
[Nausea
(Retch;Dry Vomiting)and Vomiting]
恶心和呕吐
[Hematemesis
(Vomiting of blood)]
呕血
[Hematochezia (Hemafecia)]
便血
[Diarrhea]
腹泻
[Constipation
(Obstipation)]
便秘
[Vertigo
(Giddiness; Dizziness)]
眩晕
[Jaundice (Icterus)]
黄疸
[Convulsion]
惊厥
[Disturbance of
consciousness]
意识障碍
[Hematuria]
血尿
[Frequent
micturition,urgent micturition and dysuria]
尿
频,尿急和尿痛
[Incontinence of urine]
尿失禁
; [Retention of urine]
尿潴留(
1
)发热的表示方
法
[Infective (Septic)fever]
感染性发热
[Non-infective
(Aseptic)fever]
非感染性发热
[Dehydration
(Inanition)fever]
脱水热
[Drug fever]
药物热
[Functional
hypothermia]
功能性低热
[Absorption
fever]
吸收热
[Central fever]
中枢性发热
[Fever type]
热型
▲
[Continuous fever]
稽留热
▲
[Remittent
fever]
驰张热
▲
[Intermittent fever]
间歇热
▲
[Undulant fever]
波状热
▲
[Recurrent fever]
回归热
▲
[Periodic fever]
周期热
▲
[Irregular fever]
不规则热
▲
[Ephemeral fever]
短暂热
▲
[Double peaked
fever]
双峰热
[Fever of
undetermined(unknown) origin, FUO]
不明原因发热
[Rigor
(shivering;chill;shaking chill;ague)]
寒战
[Chilly Sensation
(Fell chilly;cold fits;coldness)]
畏寒
[Ultra-
hyperpyrexia]
超高热
[Hyperthermia (A high
fever;hyperpyrexia;ardent fever)]
高热
[Moderate fever]
中度发热
[Hypothermia (Low-
grade fever;slight fever;subfebrile temperature)]
低热
[Become
feverish (Have a temperature)]
发热
[Crisis]
骤降
[Lysis]
渐降
[Typhoid fever]
伤寒热
[Rheumatic
fever]
风湿热
[Cancerous fever]
癌性发热
[Fervescence period]
升热期
[Defervescence period]
退
热期
[Persistent febrile period]
持续发热期(
2
)疼痛的表示方法
[Backache
(Back pain)]
背痛
[Lumbago]
腰痛
[Headache]
头痛
▲
[Vasomotor headache]
血管舒缩性头痛
▲
[Post-traumatic
headache]
创伤后头痛
▲
[Migraine headache]
偏头痛
▲
[Cluster headache]
丛集性头痛
[Chest pain]
胸痛
[Precardial pain]
心前区痛
[Retrosternal pain]
胸骨后痛
[Abdominal pain (Stomachache)]
腹
痛
[Acrodynia
(pain in limbs)]
肢体痛
[Arthrodynia (Arthralgia)]
关节痛
[Dull pain]
钝痛
[Sharp
pain]
锐痛
[Twinge pain]
刺痛
[Knife-
like pain (Piercing pain)]
刀割(刺)样痛
[Aching pain]
酸
痛
[Burning
pain]
烧灼痛
[Colicky
(Griping;cramp) pain]
绞痛
[Colic]
绞痛
[Bursting
pain]
胀痛
(撕裂痛)
[Hunger pain]
饥饿痛
[Tic
pain]
抽搐痛
[Bearing-down
pain]
坠痛
[Shock-like
pain]
电击样痛
[Jumping pain]
反跳痛
[Tenderness pain]
触痛(压痛)
[Girdle-like pain]
束带样痛
[Wandering pain]
游走性痛
[Throbbing pain]
搏动性痛
[Radiating pain]
放射性痛
[Cramping pain]
痉挛性痛
[Boring pain]
钻痛
[Intense pain]
剧痛
[Writhing pain]
痛得打滚
[Dragging pain]
牵引
痛
[Labor
pain]
阵痛
[Cancerous pain]
癌性疼痛
[Referred pain]
牵涉痛
[Persistent pain
(Unremitting pain)]
持续性痛
[Constant pain]
经常性痛
[Intermittent pain]
间歇性痛
3
)水肿的表示方法
[Mucous
edema (Myxedema)]
粘液性水肿
[Cardiac
(Cardiogenic) edema]
心源性水肿
[Nephrotic
(renal) edema]
肾源性水肿
[Hepatic
edema]
肝源性水肿
[Alimentary
(Nutritional) edema]
营养不良性水肿
[Angioneurotic edema]
血管神经性水肿
[Pitting]
凹陷性
[Nonpitting]
非凹陷性
[Localized (Local) edema]
局限性水肿
[Generalized edema (Anasarca)]
全身性水肿
[Hydrops]
积水
[Elephantiasic crus]
橡皮肿
[Cerebral(Brain) edema]
脑水肿
[Pulmonary
edema (Hydropneumonia0]
肺水肿
[Hydrocephalus]
脑积水
[Edema of
endoscrinopathy]
内分泌病性水肿
[Invisible (Recessive) edema]
隐性水肿
[Frank
edema]
显性水肿
[Inflammatory edema]
炎性水肿
[Idiopathic edema]
特发性水肿
[Cyclical edema]
周期性水肿
[Ascites (Abdominal
effusion;hydroperiotoneum)]
腹水
[Pleural
effusion (Hydrothorax)]
胸水
[Pericardial effusion
(Hydropericardium)]
心包积液
[Bronchoedema]
支气管水肿
[Slight
(Mild)]
轻度
[Moderate]
中度
[Serious]
重度
[Transudate]
漏出液
; [Exudate]
渗出液
(
4
)呼吸困难的表示方法
[Cardiac dyspnea]
心原性呼吸困难
[Inspiratory]
吸气性
[Expiratory]
呼气性
[Mixed]
混合性
[Obstructive]
梗阻性
[Dyspnea at rest]
静息时呼吸困难
[Dyspnea on exertion]
活动时呼吸困难
[Dyspnea on lying down]
躺下时呼吸困难
[Paroxysmal nocturnal dyspnea,PND]
夜间阵发性呼吸困难
[Orthopnea]
端坐呼吸
; [Asthma]
哮喘
[Cardiac asthma]
心源性哮喘
[Bronchial asthma]
支气管性哮喘
[Hyperpnea]
呼吸深快
[Periodic
breathing]
周期性呼吸
; [Tachypnea (Rapid or fast breathing;accelerated
breathing;short of
breath)]
气促
[Bradypnea (Slow breathing)]
呼吸缓慢
[Irregular breathing]
不规则呼吸
(
5
)皮肤粘膜出血的表示方法
[Bleeding spots in the
skin]
皮肤出血点
[Petechia]
瘀点
[Eccymosis]
瘀斑
[Purpura]
紫癜
[Splinter hemorrhage]
片状出血
[Oozing of the blood (Errhysis)]
渗血
[Blood
blister (Hemophysallis)]
血疱
[Hemorrhinia (Nasal bleeding)]
鼻衄
[Ecchymoma]
皮下血肿
(
6
)咳嗽与咯痰的表示方法
[Dry cough (Nonproductive cough;hacking cough)]
干咳
[Sharp
cough]
剧咳
[Wet
cough (Moist cough)]
湿咳
[Productive cough (Loose cough)]
排痰性咳
[Chronic
cough]
慢性咳嗽
[Irritable cough]
刺激性咳嗽
[Paroxysmal cough]
发作性(阵发性)咳嗽
[Cough continually]
持续性咳嗽
[Spasmodic cough]
痉挛性咳嗽
[Whooping cough]
百日咳
[Winter cough]
冬季咳
[Wheezing
cough]
喘咳
[Short cough]
短咳
; [Distressed cough]
难咳
[Shallow cough]
浅咳
[Droplet]
飞沫
[Frothy
sputum]
泡沫样痰
[Bloody sputum]
血痰
[Mucous (Mucoid) sputum]
粘液样痰
[Purulent
sputum]
脓痰
[Mucopurulent sputum]
粘液脓性痰
[White (Yellow,green) sputum]
白(黄
,
绿)痰
[Fetid (Foul) sputum]
恶臭痰
[Iron-rust (Rusty) sputum]
铁锈色痰
[Chocolate coloured sputum]
巧克力色痰
[Thick
sputum]
浓痰
[Thin sputum]
淡痰
; [Viscous sputum]
粘痰
[Transparent sputum]
透明痰
[Much
(Large amounts of) sputum]
大量痰
[Moderate
amounts of sputum]
中等量痰
[Not much (Small amounts of )
sputum]
少量痰
(
7
)内脏出血的表示方法
; *Goldstein’
s
hemoptysis]
戈耳斯坦氏咯血
[Massive
hematemesis]
大量呕血
; [Epistasis (Nosebleed;Nasal bleeding;
Hemorrhinia;rhinorrhagia)]
鼻衄
[Hematuria]
血尿
[Initial hematuria]
初血尿
[Idiopathic hematuria]
特发性血尿
[Painless hematuria]
无痛性血尿
[Terminal hematuria]
终末性血尿
[Gross (Macroscopic) hematuria]
肉眼血尿
[Microscopic hematuria]
镜下血尿
[Hematuria in the whole process of
urination]
全程血尿
; [Gingival bleeding (Ulaemorrhagia;gum bleeding)]
牙龈出血
[Hematochezia]
便血
[Bloody stool]
血便
[Black
stool (Melena)]
黑便
[Tarry stool]
柏油样便
[Bleeding
following trauma]
外伤后出血
[Spontaneous bleeding]
自发性出血
[Bleeding Continuously]
持续出血
[Occult blood,OB]
隐血
[Hematobilia]
胆道出血
[Hemathorax]
血胸
[Hemarthrosis]
关节积血
[Hematocoelia]
腹腔积血
[Hematoma]
血肿
[Hemopericardium]
心包积血
[Cerebral hemorrhage]
脑出血
[Subarachnoid hemorrhage(SAH)]
蛛网膜下腔出血
[Excessive (Heavy) menstrual flow with passage of
clots]
月经量多伴血块
[Mild (Moderate) menses]
月经量少(中等)
[Painless Vaginal bleeding]
无痛性阴道出血
[Postcoital bleeding]
性交后出血
[Pulsating bleeding]
搏动性出血
[Post-
operation wound hemorrhage]
术后伤口出血
[Excessive bleeding after denal extraction]
拔牙后出血过多
(
< br>8
)紫绀的表示方法
[Congenital cyanosis]
先天性紫绀
[Enterogenous]
肠源性
[Central]
中枢性
[Peripheral]
周围性
; [Mixed]
混合性
[Acrocyanosis]
指端紫绀
< br>(
9
)恶心与呕吐的表示方法
[Vomiturition (Retching)]
干呕
[Feel
nauseated]
恶心感
[Postprandial nausea]
饭后恶心
[Hiccup]
呃逆
[Sour regurgitation]
返酸
[Fecal
(Stercoraceous) vomiting]
吐粪
[undigested food Vomiting]
吐不消化食物
[Bilious Vomiting]
吐胆汁
(
10
)腹泻与便秘的表示方法
< br>
[Moning diarrhea]
晨泻
[Watery
(Liquid)diarrhea]
水泻
[Mucous diarrhea]
粘液泻
[Fatty
diarrhea]
脂肪泻
[Chronic (Acute)]
慢性(急性)
[Mild diarrhea]
轻度腹泻
[Intractable (Uncontrolled)diarrhea]
难治性腹泻
[Protracted diarrhea]
迁延性腹泻
[Bloody stool]
血梗
[Frothy
stool]
泡沫样便
[Formless (Formed)stool]
不成形(成形)便
[Loose (Hard) stool]
稀(硬)便
[Rice-water stool]
米泔样便
[Undigested stool]
不消化便
[Dysenteric diarrhea]
痢疾样腹泻
[Inflammatory diarrhea]
炎症性腹泻
[Osmotic]
渗透性
[Secretory]
分泌性
; [Malabsorption]
吸收不良性
[Lienteric]
消化不良性
[Pancreatic diarrhea]
胰性腹泻
[Tenesmus]
里急后重
[Pass a
stool (Have a passage; open or relax the bowel)]
解大便
[Have a
call of nature]
便意
[Fecal incontinence (Copracrasia)]
大便失禁
[Functional constipation]
功能性便秘
[Organic
constipation]
器质性便秘
[Habitual constipation]
习惯性便秘
[Have a
tendency to be constipated]
便秘倾向
(
11
)黄疸的表示方法
[Latent (occult) jaundice]
隐性黄疸
[Clinical
jaundice]
显性黄疸
[Nuclear icterus]
核黄疸
[Physiologic icterus]
生理性黄疸
[Icterus
simplex]
传染性黄疸
[Toxemic icterus]
中毒性黄疸
[Hemolytic]
溶血性
[Hepatocellular]
肝细胞性
[Obstructive]
阻塞性
[Congenital]
先天性
; [Familial]
家族性
; [Cholestatic]
胆汁淤积性
[Hematogenous]
血源性
[Malignant]
恶性
[Painless]
无痛性
(<
/p>
12
)意识障碍的表示方法
[Somnolence]
嗜睡
[Confusion]
意识模糊
[Stupor]
昏睡
[Coma]
昏迷
[Delirium]
谵妄
[Syncope
(swoon; faint)]
晕厥
[Drowsiness]
倦睡
(
13
)排尿的表示方法
[Enuresis (Bed-wetting)]
遗尿
[Anuria]
无尿
[Emiction
interruption]
排尿中断
[Interruption of urinary stream]
尿线中断
[Nocturia]
夜尿
[Oliguria]
少尿
[Polyuria]
多尿
[Pass water (Make water; urinate; micturition)]
排尿
[Frequent
micturition (Frequency of micturition; fruquent
urination;
Pollakiuria)]
尿频
[Urgent
micturition (Urgency of urination or micturition)]
尿急
[Urodynia
(Pain on micturition; painful micturition;
alginuresis; micturition pain)]
尿痛
[Dysuria
(Difficulty in micturition; disturbance of
micturition)]
排尿困难
[Small urinary stream]
尿线细小
[Void
with a good stream]
排尿通畅
[Guttate emiction (Dribbling
following urination;terminal dribbling)]
滴尿
[Bifurcation of urination]
尿流分
*
[Residual
urine]
残余尿
[Extravasation of urine]
尿外渗
[Stress incontinence]
压力性尿失禁
[Overflow incontinence]
溢出性尿失禁
[Paradoxical in continence]
反常性尿失禁
3
.少见症状
[Weekness( Debility; asthenia;
debilitating)]
虚弱(无力)
[Fatigue (Tire; lassitude)]
疲乏
[Discomfort
(Indisposition; malaise)]
不适
[Wasting (thin; underweight;
emaciation; lean)]
消瘦
[Night sweating]
盗汗
[Sweat
(Perspiration)]
出汗
[Cold sweat]
冷汗
[Pruritus
(Iching)]
搔痒
[Asthma]
气喘
[Squeezing (Tightness; choking; pressing)
sensation of the chest]
胸部紧缩
(压榨)感
[Intermittent claudication]
间歇性跛行
[Difficulty in swallowing( Dysphagia; difficult
swallowing; acataposis)]
吞咽困难
[Epigastric (Upper abdominal) discomfort]
上腹部不适
[Anorexia (Sitophobia)]
厌食
[Poor appetite (Loss of appetite)]
纳差
[Heart-
burn( Pyrosis)]
胃灼热
[Stomachache( Pain in stomach)]
胃部痛
[Periumbilial pain]
脐周痛
[Belching (Eructation)]
嗳气
[Sour
regurgitation]
返酸
[Abdominal distention(bloating)]
腹胀
[Pass gas(
Break wink)]
肛门排气
[Small(Large) stool]
大便少(多)
[Expel(Pass) worms]
排虫
[Pain over the liver]
肝区痛
[Lumbago]
腰痛
[Pica(Parorexia; allotriophagy)]
异食癖
[Dysmenorrhea]
痛经
[Menoxenia (Irregular menstruation)]
月经不调
[Polymenorrhea (Epimenorrhea)]
月经过频
[Oligomenorrhea]
月经过少
[Excessive menstruation
(Menorrhagia; menometrorrhagia; hypermenorrhea)]
经量过多
[Hypomenorrhea (Scantymenstruation)]
经量过少
[Menopause (Menostasia; menostasis)]
绝经
[Amenorrhea
(Menoschesis)]
闭经
[Leukorrhagia]
白带过多
[A***uality (lack of libido)]
无性欲
[Hypo***uality]
性欲低下
[Hyper***uality]
性欲亢进
[Prospermia (Ejaculatio praecox)]
早泄
[Impotency
(impotence)]
阳萎
; [Nocturnal emission (Spermatorrhea)]
遗精
[Lack of
potency]
无性交能力
[Hair loss]
脱发
[Joint pain (Arthralgia; arthrodynia)]
关节痛
[Polydipsia (Excessive thirst)]
多饮(烦渴)
[Polyphagia (Excessive appetite; hyperorexia;
bulimia)]
多食
[Cold (Heat) intolerance]
怕冷(热)
[Dwarfism (Excessive height)]
身材矮小(高大)
[Excessive sweating]
多汗
[Hands tremble]
手抖
[Obesity
(Fatty)]
肥胖
[Agitation (Anxiety;nervous irritability)]
焦虑(忧虑)
[Mania]
躁狂
[Hallucination]
幻觉
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