病历文书中常用基本用语的英文翻译
导语：
来源：梅斯医学
1、抗生素医嘱[Antibiotic order] 
·Prophylaxis [预防性用药] 
Duration of order[用药时间] 24hr 
Procedure[操作，手术] 
·Empiric therapy [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[其它] 
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] 
·Activity [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] 
documented翻译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[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素<8] 
*chemotherapy or surgery with Hb <10[血素<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] 
Principal Diagnosis[主要诊断] 
Secondary Diagnosis[次要诊断] 
Complications[并发症] 
Operation[手术名称] 

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