住院病历英文翻译幻灯片.docx

最全的医学英语之NO.12014-03-05保研助手最全的医学英语之NO.11、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]:*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]*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 l