医学英语大全.docx
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医学英语大全.docx
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医学英语大全
医学英语大全
1、抗生素医嘱[Antibioticorder]
·Prophylaxis[预防性用药]Duration of oder[用药时间]24hr
Procedure[操作,手术]
·Empirictheraphy[经验性治疗]
Suspectedsiteandorganism[怀疑感染的部位和致病菌] 72hr
Cultures ordered[是否做培养]
·Documentedinfection[明确感染]
Siteandorganism[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]
Noknownallergy[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 /transferto[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]
·Vitalsigns[测生命体征]
·I/O[记进出量]
·Allergies[过敏]
3、住院病历[casehistory]
·Identification[病人一般情况]
Name[性名]
Sex[性别]
Age[年龄]
Marriage[婚姻]
Person tonotifyandphoneNo.[联系人及电话]
Race[民族]
I.D.No.[身份证]
Admissiondate[入院日期]
Sourceofhistory[病史提供者]
Reliability ofhistory[可靠程度]
MedicalrecordNo[病历号]
BusinessphoneNo.[工作单位电话]
Homeaddressandphone No.[家庭住地及电话]
·Chiefcomplaint[主诉]
·Historyofpresent illness[现病史]
·Past History[过去史]
Surgical[外科]
Medical[内科]
Medications[用药]
Allergies[过敏史]
SocialHistory[社会史]
Habits[个人习惯]
Smoking[吸烟]
Family History[家族史]
Ob/GynHistory[婚姻/生育史]
Alcoholuse[喝酒]
·ReviewofAystems[系统回顾]
General[概况]
Eyes,Ears,Noseandthroat[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]
·PhysicalExam[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]
Heartrate[心率]
Heartrhythm[心律]
HeartBorder[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]
cranialnerves[颅神经]
sensation[感觉]
Motor[运动]
*SpecialP.E.ondiseasedorgansystem[专科情况]
*RadiographicFindings[放射]
*LaboratoryFindings[化验]
*Assessment[初步诊断与诊断依据]
*Summary[病史小结]
*TreatmentPlan[治疗计划]
4、输血申请单[Bloodbank requisitionform]
(1)reasonfor infusion[输血原因]
▲红细胞[packed redcells,wshedRBCs]:
*Hb<8.5[血色素<8.5]
*>20%bloodvolumelost[>20%血容量丢失]
*cardio-pulmonarybypass withanticipatedHb<8[心肺分流术伴预计血色素
<8]
*chemotherapyorsurgerywithHb<10[血色素<10的化疗或手术者]
▲全血[wholeblood]:
massiveon-going bloodloss[大量出血]
▲血小板[platelets]:
*massive bloodtransfusion>10units[输血10单位以上者]
*platelet count<50×103/μlwithactivebleedingorsurgery[血小板<5万伴活
动性出血或手术者]
*Cardio-pulmonarybypassuith pl<100×103/μlwith octivebleeding[心肺分流
术伴血小板<10万,活动性出血者]
*Plateletcount<20×103/μl[血板<2万]
▲新鲜冰冻血浆[freshfrozenplasma]:
*documentedabnormal PTorPTTwithbleedingorSurgery[PT、PTT异常的
出血或手术病人]
*specificclottingfactordeficiencieswithbleeding/surgerg[特殊凝血因子缺乏
的出血/手术者]
*bloodtransfusion>15units[输血>15个单位]
*warfarinorantifibrinolytictherapywithbleeding[华法令或溶栓治疗后出血]
*DIC[血管内弥漫性凝血]
*AntithrombinIIIdficiency[凝血酶III 缺乏]
(2)输血要求[request forbloodcomponents]
*patientbloodgroup[血型]
*Hasthepatienthadtransfusionorpregnancyin thepast3months?
[近3个月,
病人是否输过血或怀孕过?
]
*Type andcrossmatch[血型和血交叉]
*Units orml[单位或毫升]
5、出院小结[discharge summary]
PatientName[病人姓名]
Medical RecordNo.[病历号]
Attending Physician[主治医生]
Date ofAdmission[入院日期]
DateofDischarge[出院日期]
PirncipalDiagnosis[主要诊断]
SecondaryDiagnosis[次要诊断]
Complications[并发症]
Operation[手术名称]
ReasonforAdmission[入院理由]
PhysicalFindings[阳性体征]
Lab/X-rayFindings[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]
SpecialInstructiontothePatient(diet,physicalactivity)[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/dischargerecord]
·Patientname[病人姓名]
·race[种族]
·address[地址]
·religion[宗教]
·medicalservice[科别]
·admit(discharge)date[入院(出院)日期]
·Length of stay[住院天数]
·guarantorname [担保人姓名]
·nextofkinorpersonto notify[需通知的亲属姓名]
·relation topatient[与病人关系]
·previousadmitdate[上次住院日期]
·admittingphysician[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]
·secondarydiagnosis[次要诊断]
·adversereactions(complications)[副作用(合并症)]
·incisiontype[切口类型]
·healingcourse[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.oftimes[抢救次数]
·recovered-No.oftimes[成功次数]
·Diagnosis qualitativeanalysis[诊断质量]
OP.adm.anddischargeDxconcur[门诊入院与出院诊断符合率]
ClinicalandpathologicalDx concur[临床与病理诊断符合率]
Pre- andpost-operativeDxconcur[术前术后诊断符合率]
·Dxdeterminedwith in24hours(3 days)afteradmission[入院后24小时(3
天)内确诊]
·Dischargestatus[出院状况]
recovered[治愈]
improved[好转]
notimproved[未愈]
died[死亡]
·Dispositon[去向]
home[家]
againstmedicalad[自动出院]
autosy[尸检]
transferred to[转院到]
医学英语常用前后缀
医学英语常用前后缀·a-[无,缺]▲anemia[贫血] atonia[无张力]asymptomatic[无症状的] amenorrhea[闭经] ·ab-[分离]abduct [外展]abscision[切除]·acou(acu)-[听觉]acumeter[听力计]acouophone[助听器]·acro-[肢端] acromegaly[肢端肥大症] acromastitis[乳头炎]·a
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