住院病历英文翻译.docx

最全的医学英语之NO.1
2014-03-05 保研助手

最全的医学英语之NO.1

1、抗生素医嘱[Antibiotic order] 
Prophylaxis  预防性用药
Duration of oder 用药时间
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
Cultures ordered 做培养
Documented infection 明确感染
Site and organism 部位和致病菌
Explanation required  解释理由
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 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  姓名
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 Systems  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, washed 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]
*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]
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)[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]
OP.adm.and 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）内确诊]
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]

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