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1、. .医学英语大全1、抗生素医嘱Antibiotic orderProphylaxis 预防性用药 Duration of oder用药时间 24hrProcedure操作，手术Empiric theraphy 经历性治疗Suspected site and organism疑心感染的部位和致病菌 72hrCultures ordered是否做培养Documented infection明确感染Site and organism部位和致病菌 5daysOther其他Explanation required 解释理由 24hrAntibiotic allergies何种抗生素过敏No known
2、 allergy 无的过敏Drug+dose+Route+frequency药名+剂量+途径+次数2、医嘱首页Admission / transferAdmit / transfer to 收入或转入Resident 住院医师 Attending主治医师Condition 病情Diagnosis诊断Diet 饮食Acitivity 活动Vital signs测生命体征I / O 记进出量Allergies过敏3、住院病历case historyIdentification 病人一般情况Name性名Sex性别Age 年龄Marriage婚姻Person to notify and phone N
3、o.联系人及Race民族I.D.No.Admission date入院日期Source of history病史提供者Reliability of history可靠程度Medical record No病历号Business phone No.工作单位Home address and phone No.家庭住地及Chief complaint主诉History of present illness现病史Past History过去史Surgical外科Medical科Medications用药Allergies过敏史Social History社会史Habits个人习惯Smoking吸烟Fa
4、mily History家族史Ob/Gyn History 婚姻/生育史Alcohol use喝酒Review of Aystems系统回忆General概况Eyes,Ears,Nose and throat五官Pulmonary呼吸Cardiovascular心血管GI消化GU生殖、泌尿系统Musculoskeletal肌肉骨骼Neurology神经系统Endocrinology分泌系统Lymphatic/Hematologic淋巴系统/血液系统Physical Exam体检Vital Signs生命体征P脉博Bp血压R呼吸T温度Height身高Weight体重General概况HEENT五
5、官Neck颈部Back/Chest背部/胸部Breast乳房Heart心脏Heart rate心率Heart rhythm心律Heart Border心界Murmur杂音Abdomen腹部Liver肝Spleen脾Rectal直肠Genitalia生殖系统Extremities四肢Neurology神经系统cranial nerves颅神经sensation感觉Motor运动*Special P.E. on diseased organ system专科情况*Radiographic Findings放射*Laboratory Findings化验*Assessment初步诊断与诊断依据*Su
6、mmary病史小结*Treatment Plan治疗方案4、输血申请单Blood bank requisition form(1)reason for infusion输血原因红细胞packed red cells, wshed RBCs:*Hb8.5 血色素20% blood volume lost 20%血容量丧失*cardio-pulmonary bypass with anticipated Hb 8心肺分流术伴预计血色素8*chemotherapy or surgery with Hb 10血色素10 units输血10单位以上者*platelet count 50103/l wit
7、h active bleeding or surgery血小板5万伴活动性出血或手术者*Cardio-pulmonary bypass uith pl100103/l with octive bleeding心肺分流术伴血小板10万，活动性出血者*Platelet count 20103/l血板15units输血15个单位*warfarin or antifibrinolytic therapy with bleeding华法令或溶栓治疗后出血*DIC血管弥漫性凝血*Antithrombin III dficiency凝血酶III 缺乏(2)输血要求request for blood comp
8、onents*patient blood group血型*Has the patient had transfusion or pregnancy in the past 3 months 近3个月，病人是否输过血或怀孕过.*Type and crossmatch血型和血穿插*Units or ml单位或毫升5、出院小结discharge summaryPatient Name病人Medical Record No.病历号Attending Physician主治医生Date of Admission入院日期Date of Discharge出院日期Pirncipal Diagnosis主要诊
9、断Secondary Diagnosis次要诊断Complications并发症Operation手术名称Reason for Admission入院理由Physical Findings阳性体征Lab/X-ray Findings化验及放射报告Hospital Course住院诊治经过Condition出院状况Disposition出院去向Medications出院用药Prognosis预后Special Instruction to the Patient(diet, physical activity)出院指导饮食，活动量Follow-up Care随随访6、住院/出院病历首页Admis
10、sion/discharge recordPatient name病人race种族address地址religionmedical service科别admit (discharge) date入院出院日期Length of stay 住院天数guarantor name 担保人next of kin or person to notify需通知的亲属relation to patient与病人关系previous admit date上次住院日期admitting physician 入院医生attending phgsician主治医生admitting diagnosis入院诊断fina
11、l (principal) diagnosis最终主要诊断secondary diagnosis次要诊断adverse reactions (complications)副作用合并症incision type切口类型healing course愈合等级operative (non-operative) procedures手术非手术操作nosocomial infection院感染consutants会诊Critical-No. of times抢救次数recovered-No. of times成功次数Diagnosis qualitative analysis诊断质量OP.adm.and
12、discharge Dx concur 门诊入院与出院诊断符合率Clinical and pathological Dx concur临床与病理诊断符合率Pre- and post-operative Dx concur 术前术后诊断符合率Dx determined with in 24 hours (3 days) after admission入院后24小时3天确诊Discharge status出院状况recovered治愈improved好转not improved未愈died 死亡Dispositon去向home家against medical ad自动出院autosy尸检transferred to转院到医学英语常用前后缀医学英语常用前后缀a-无，缺 anemia贫血 atonia无力 asymptomatic无病症的 amenorrhea闭经 ab-别离 abduct 外展 abscision切除 acou (acu)-听觉 acumeter 听力计 acouophone助听器 acro-肢端 acromegaly肢端肥大症 acromastitis乳头炎 ad (af, an)-邻近，向上
