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**]
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+dose+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[case 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**]
race[民族]
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**]
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[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 use[喝酒]
review of aystems[系统回顾]
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[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]
sensation[感觉]
motor[运动]
special 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]
summary[病史小结]
treatment plan[**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。
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]
blood transfusion >15units[输血》15个单位]
warfarin or antifibrinolytic therapy with bleeding[华法令或溶栓**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]
pirncipal diagnosis[主要诊断]
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[admission/discharge record]
patient name[病人姓名]
race[种族]
address[地址]
religion[宗教]
medical service[科别]
admit (discharge) date[入院（出院）日期]
length of stay [住院天数]
guarantor name [担保人姓名]
next of kin or person to notify[需通知的亲属姓名]
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]
final (principal) diagnosis[最终（主要）诊断]
secondary diagnosis[次要诊断]
adverse reactions (complications)[***（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[院内感染]
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]
医学英语词汇
welcomevt.n.欢迎 a.受欢迎的。offervt.n.提供 贡献。be about to 不久 就要，即将。trainingn.训练 培养。programn.规划 教学 大纲。generala.一般的，普遍的。basica.基本的，基础的。coursen.课程 过程 疗程。biologyn...
医学英语词汇
forensic medicine法医学。doctor,physician医生，医师，内科医师family doctor家庭医生。pediatrician,pediatrist儿科医师gynecologist 医师。tocologist,obstetrician产科医师neurologist神经专家...
医学英语词汇
influenza p18 influenza nfl enz n.流行 冒 简写flu 家畜流行 冒。acute kjut adj.严重的，急性的 敏锐的 激烈的 尖声的。chronic krnk adj.慢性的 长期的 习惯性的。viral var l adj.滤过性毒菌引起的 滤过性毒菌的。i...