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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[Antibioticorder]Prophylaxis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+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Sourceofhistory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ReviewofSystems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[Bloodbankrequisitionform](1)reasonforinfusion[输血原因]▲红细胞[packedredcells,washedRBCs]:*Hb8.5[血色素8.5]*20%bloodvolumelost[20%血容量丢失]*cardio-pulmonarybypasswithanticipatedHb8[心肺分流术伴预计血色素8]*chemotherapyorsurgerywithHb10[血色素10的化疗或手术者]▲全血[wholeblood]:massiveon-goingbloodloss[大量出血]▲血小板[platelets]:*massivebloodtransfusion10units[输血10单位以上者]*plateletcount50×103/μlwithactivebleedingorsurgery[血小板5万伴活动性出血或手术者]*Cardio-pulmonarybypassuithpl100×103/μlwithoctivebleeding[心肺分流术伴血小板10万，活动性出血者]*Plateletcount20×103/μl[血板2万]▲新鲜冰冻血浆[freshfrozenplasma]:*documentedabnormalPTorPTTwithbleedingorSurgery[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]*bloodtransfusion15units[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]*Unitsorml[单位或毫升]5、出院小结[dischargesummary]PatientName[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]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-upCare[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]Lengthofstay[住院天数]guarantorname[担保人姓名]nextofkinorpersontonotify[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)[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]nosocomialinfection[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