住院病历英文翻译

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1、最全的医学英语之NO.12014-03-05保研助手最全的医学英语之N0.11、抗生素医嘱AntibioticorderProphylaxis预防性用药Durationofoder用药时间Procedure操作，手术Empirictheraphy经验性治疗Suspectedsiteandorganism怀疑感染的部位和致病菌Culturesordered做培养Documentedinfection明确感染Siteandorganism部位和致病菌Explanationrequired解释理由Antibioticallergies何种抗生素过敏Noknownallergy无已知的过敏Drug+d

2、ose+Route+frequency药名+剂量+途径+次数2、医嘱首页Admission/transferAdmit/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生命体征I/O记进出量Allergies过敏3、住院病历casehistoryIdentification病人一般情况Name姓名Sex性别Age年龄Marriage婚姻PersontonotifyandphoneNo.联系人及电话Race民族I.D.No.身份证Admissiondate入院日期So

3、urceofhistory病史提供者Reliabilityofhistory可靠程度MedicalrecordNo病历号BusinessphoneNo工作单位电话HomeaddressandphoneNo家庭住地及电话Chiefcomplaint主诉Historyofpresentillness现病史PastHistory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FamilyHistory家族史Ob/GynHistory婚姻/生育史Alcoholuse喝酒ReviewofS

4、ystems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VitalSigns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He

5、artBorder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Bloodbankrequisitionform(1)reasonforinfus

6、ion输血原因红细胞packedredcells,washedRBCs:*Hb8.5血色素20%bloodvolumelost20%血容量丢失*cardio-pulmonarybypasswithanticipatedHb8心肺分流术伴预计血色素8*chemotherapyorsurgerywithHb10血色素10units输血10单位以上者*plateletcountv50x103/plwithactivebleedingorsurgery血小板v5万伴活动性出血或手术者*Cardio-pulmonarybypassuithplv100x103/plwithoctivebleeding心肺

7、分流术伴血小板10万，活动性出血者*Plateletcount15units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requestforbloodcomponents*patientbloodgroup血型*Hasthepatienthadtransfusionorpregnancyinthepast3months?近3个月，病人是否输过血或怀孕过？*Typeandcrossmatch血型和血交叉*Uni

8、tsorml单位或毫升5、出院小结dischargesummaryPatientName病人姓名MedicalRecordNo.病历号AttendingPhysician主治医生DateofAdmission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HospitalCourse住院诊治经过Condition出院状况D

9、isposition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-upCare随随访6、住院/出院病历首页Admission/dischargerecordPatientname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Lengthofstay住院天数guarantorname担保人姓名nextofkinorpersontonotify

10、需通知的亲属姓名relationtopatient与病人关系previousadmitdate上次住院日期admittingphysician入院医生attendingphgsician主治医生admittingdiagnosis入院诊断final(principal)diagnosis最终(主要)诊断secondarydiagnosis次要诊断adversereactions(complications)畐U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

11、infection院内感染consutants会诊Critical-No.oftimes抢救次数recovered-No.oftimes成功次数Diagnosisqualitativeanalysis诊断质量OP.adm.anddischargeDxconcur门诊入院与出院诊断符合率ClinicalandpathologicalDxconcur临床与病理诊断符合率Pre-andpost-operativeDxconcur术前术后诊断符合率Dxdeterminedwithin24hours(3days)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transferredto转院到阅读原文举报