医学英语大全
1、 抗生素医嘱[Antibiotic order]
·Prophylaxis [预防性用药] Duration of oder[用药时间] 24hr
Procedure[操作，手术]
·Empiric theraphy [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]
·Documented infection[明确感染]
Site and organism[部位和致病菌] 5days
·Other[其他]
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]
·Acitivity [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]
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]
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]
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]
nsation[感觉]
Motor[运动]
