《有关医学常用知识.docxVIP

最全的医学英语你爱信不信呀(请各位不要留言) 来源： 刘辉的日志 1、 抗生素医嘱[Antibiotic order] ·Prophylaxis [预防性用药] Duration of oder[用药时间] 24hrrocedure[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] 72hrCultures 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 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 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]*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]:*Hb8.5 [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]*chemother