病历文书中常用基本用语的英文翻译
导语：
来源：梅斯医学
1、抗生素医嘱[Antibiotic order]
·Prophylaxis [预防性用药]
Duration of order[用药时间] 24hr
Procedure[操作，手术]
·Empiric therapy [经验性治疗]
Suspected site and organism[怀疑感染的部位和致病菌] 72hr
Cultures ordered[是否做培养] 脍炙人口
·Documented infection[明确感染]
八角苗
Site and organism[部位和致病菌] 5days
·Other[其它]
Explanation required [解释理由] 24hr
·Antibiotic allergies[何种抗生素过敏]
No known allergy [无已知的过敏]
·Drug do Route frequency[药名 剂量 途径 次数]
2、医嘱首页[Admission / transfer]
·Admit / 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]
·Activity [活动]
·Vital signs[测生命体征]
·I / O [记进出量]
·Allergies[过敏]
3、住院病历[ca history]
·Identification [病人一般情况]
Name[性名]
Sex[性别]
Age [年龄]
Marriage[婚姻]
Person to notify and phone No.[联系人及电话]
Race[民族]
I.D. No.[身份证]
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.[工作单位电话]
Home address and phone No.[家庭住地及电话]
·Chief complaint[主诉]
·History of prent illness[现病史]
·Past History[过去史]
Surgical[外科]
Medical[内科]
Medications[用药]
Allergies[过敏史]
Social History[社会史]
Habits[个人习惯] wps备份
Smoking[吸烟]
Family History[家族史]
Ob/Gyn History[ 婚姻/生育史]
Alcohol u[喝酒]
·Review of Aystems[系统回顾]
General[概况]
Eyes, Ears, No 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[内分泌系统]
Lymphatic/Hematologic[淋巴系统/血液系统]
·Physical Exam[体检] 闻鸡起舞
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[五官]
Neck[颈部]
Back/Chest[背部/胸部]
Breast[乳房]
Heart[心脏]
Heart rate[心率]
元旦晚会节目单
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]
约舔Neurology[神经系统]
cranial nerves[颅神经]
nsation[感觉]
Motor[运动]
*Special P.E. on diad organ system[专科情况]
*Radiographic Findings[放射]
*Laboratory Findings[化验]
*Asssment[初步诊断与诊断依据]
*Summary[病史小结]
*Treatment Plan[治疗计划]
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]:
*Hb<8.5 [血色素<8.5]
*>20% blood volume lost [>20%血容量丢失]
*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的化疗或手术者]
▲全血[whole blood]:
massive on-going blood loss[大量出血]
▲血小板[platelets]:
*massive blood transfusion >10 units[输血10单位以上者]
*platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活动性出血或手术者]
*Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流术伴血小板<10万，活动性出血者]
*Platelet count <20×103/μl[血板<2万]
▲新鲜冰冻血浆[fresh frozen plasma]:
*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的出血或手术病人]
*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手术者]
冬菇焖鸡
*blood transfusion >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[血管内弥漫性凝血]
*Antithrombin III dficiency[凝血酶III 缺乏]
(2)输血要求[request for blood components]
*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 [血型和血交叉]
*Units or ml[单位或毫升]
5、出院小结[discharge summary]
Patient Name[病人姓名]
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]
Principal Diagnosis[主要诊断]
Secondary Diagnosis[次要诊断]
太平天国地图Complications[并发症]
Operation[手术名称]
