1、 抗生素医嘱[Antibiotic order]
·Prophylaxis [预防性用药] Duration of oder[用药时间] 24hr
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] 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[其他]
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]
·Acitivity [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]
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, wshed RBCs]:
*Hb<8.5 [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 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[华法令或溶栓治疗后出血]
*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]
Pirncipal Diagnosis[主要诊断]
Secondary Diagnosis[次要诊断]
Complications[并发症]
Operation[手术名称]
Reason for Admission[入院理由]
Physical Findings[阳性体征]
Lab/X-ray Findings[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]
Special Instruction to the Patient(diet, physical activity)[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/discharge record]
·Patient name[病人姓名]
·race[种族]
·address[地址]
·religion[宗教]
·medical service[科别]
·admit (discharge) date[入院（出院）日期]
·Length of stay [住院天数]
·guarantor name [担保人姓名]
·next of kin or person to notify[需通知的亲属姓名]
·relation to patient[与病人关系]
·previous admit date[上次住院日期]
·admitting physician [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]
·secondary diagnosis[次要诊断]
·adverse reactions (complications)[副作用（合并症）]
·incision type[切口类型]
·healing course[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. of times[抢救次数]
·recovered-No. of times[成功次数]
·Diagnosis qualitative analysis[诊断质量]
OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率]
Clinical and pathological Dx concur[临床与病理诊断符合率]
Pre- and post-operative Dx concur [术前术后诊断符合率]
·Dx determined with in 24 hours (3 days) after admission[入院后24小时（3
天）内确诊]
·Discharge status[出院状况]
recovered[治愈]
improved[好转]
not improved[未愈]
died [死亡]
·Dispositon[去向]
home[家]
against medical ad[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] ·ad (af, an)-[邻近，向上] adrenal [肾上腺] adaxial[近轴的] annexa[附件] ·-ad[……侧] ventrad[向腹侧] cephalad[向头侧] ·adeno-[腺] adenocyte[腺细胞] adenoidism[腺体病] ·adipo-[脂肪] adiposis[肥胖症] adiponecrosis[脂肪坏死] ·adreno-[肾上腺] adrenocorticoid[肾上腺皮质激素] adrenalin[肾上腺素] adrenal[肾上腺] ·-aemia(emia)[血症] bacteremia[菌血症] leukemia[白血病] ·-albi (albino)-[白色] albumin[白蛋白] albinism[白化病] ·-algesia[痛觉] ▲hypoalgesia[痛觉减退] ·-algia[痛] ▲arthralgia[关节痛] ▲cephalgia[头痛] ▲neuralgia[神经痛] ·alkali-[碱] ▲alkalosis[碱中毒] ·alveo-[牙槽，小沟] ▲alveolitis[牙槽炎] ▲alveobronchiolitis[支气管肺泡炎] ·ambi-[复，双] ambiopia[复视] ambivert[双重性格] ·ambly-[弱] ▲amblyopia[弱视] ▲amblyaphia[触觉迟钝] ·amylo-[淀粉] ▲amyloidosis[淀粉酶] ▲amylase[淀粉酶] ·angio-[血管] ▲angiography[血管造影术] ▲angioedema[血管性水肿] ▲angeitis[脉管炎] ▲angiofibroma[血管纤维瘤] ·ante-[前] ▲antenatal[出生前的] ▲anteflexion[前屈] ·antero-[前] ▲anterolateral[前侧壁] ▲anteroventral[前腹侧] ·anti-[抗，反] ▲antibiotics[抗生素] ▲antihypertensives[降压药] ▲anticoagulant[抗凝剂] ·rarchno-[蛛网膜] ▲arachnoiditis[蛛网膜炎] ·archo-[肛门，直肠] ▲archorrhagia[肛门出血] ▲archosyrinx[直肠灌注器] ·arterio-[动脉] ▲arteriospasm[动脉痉挛] ▲arteriosclerosis[动脉硬化] ·arthro-[关节] ▲arthrocentesis[关节穿刺] ▲arthrotomy[关节切开术] ▲arthritis[关节炎] ·-ase[酶] ▲oxidase[氧化酶] ▲proteinase[蛋白酶] ·-asthenia[无力] ▲myasthenia[肌无力] ▲neurasthenia[神经衰弱] ·audio(audito)-[听力] ▲audiology[听觉学] ▲audiometer[听力计] ·auto-[自己] ▲autoimmune[自身免疫] ▲auto hemotherapy[自体血疗法] ·bacilli-[杆菌] ▲bacillosis[杆菌病] ▲bacilluria[杆菌尿] ·bacterio-[细菌] ▲bacteriology[细菌学] ▲bactericide[杀菌剂] ·baro-[压力] ▲barometer [压力计] ▲baroreceptor[压力感受器] ·bary-[迟钝] ▲barylalia[言语不清] ▲baryacusia[听觉迟钝] ·bi-[双] ▲bicuspid[二尖瓣]] ▲bilateral[两侧的] ·bili-[胆汁] ▲bilirubin[胆红素] ·bio-[生命] ▲biology[生物学] ▲biopsy[活检] ·-blast[母细胞] ▲spermatoblast[精子细胞] ▲melanoblast[成黑色素细胞] ▲osteoblast[成骨细胞] ·brachy-[短] ▲brachypnea[气短] ▲brachydactylia[短指畸形] ·brady-[迟缓] ▲bradycardia[心动过缓] ▲bradypsychia[精神不振] ·broncho-[支气管] ▲bronchoscopy[支气管镜检查] ▲bronchiostenosis[支气管痉挛] ▲bronchitis[支气管炎] ·bronchiolo-[细支气管] ▲bronchiolectasis[细支气管扩张] ·calci-[钙] ▲calcification[钙化] ▲calcicosilicosis[钙沉着症] ·carbo-[碳] ▲carbohydrate[碳水化合物] ▲carbohaemia[碳酸血症] ·carcino-[癌] ▲carcinogen[致癌物] ·cardio-[心，贲门] ▲cardiotonics[强心剂] ▲cardioplasty[贲门成形术] ·-cele[疝，肿物] ▲omphalocele[脐疝] ▲hysterocele[子宫脱垂] ▲ophthalmocele[眼球突出] ·celio-[腹] ▲celialgia[腹痛] ▲celioscopy[腹腔镜检查] ·-centesis[穿刺] ▲arthrocentesis[关节穿刺术] ▲abdominocentesis[腹穿] 3 回复：医学英语常用前后缀 ·cephalo-[头] ▲cephaloxia[斜颈] ▲cephalopathy[头部疾病] ▲cephalotomy[穿颅术] ·cerebello-[小脑] ▲cerebellitis[小脑炎] ▲cerebellum[小脑] ·cerebro-[大脑] ▲cerebritis[大脑炎] ▲cerebrology[脑学] ·chemo-[化学] ▲chemotherapy[化疗] ·chloro-[绿，氯] ▲chloroform[氯仿] ▲chloromycetin[氯霉素] ▲chlorophyll[叶绿素] ·cholangio-[胆道] ▲cholangitis[胆管炎] ▲cholangiectasis[胆管扩张] ·cholo-[胆] ▲cholagogue[利胆剂] ▲cholelithiasis[胆石症] ▲cholecystitis[胆囊炎] ▲cholesterol[胆固醇] ·chondro-[软骨] ▲chondrosarcoma[软骨肉瘤] ▲chondrification[骨软化] ·chromo-[色素] ▲cytochrome[细胞色素] ▲chromosome[染色体] ·-cide[杀……剂] ▲germicide[杀菌剂] ▲aborticide[堕胎药] ·circum-[周围] ▲circumoral[口周的] ▲circumcision[包皮环切术] ·coagulo-[凝固] ▲coagulant[凝血剂] ·colo-[结肠] ▲colotomy[结肠切开术] ▲coloptosis[结肠下垂] ·colpo (coleo)-[阴道] ▲coleospastia[阴道痉挛] ▲colposcope[阴道镜] ·contra-[反，逆] ▲contraindication[禁忌证] ▲contraceptive[避孕药] ·counter-[反，逆] ▲counteragent[拮抗剂] ▲conuterpoison[解毒剂] ·cranio-[颅] ▲craniomalacia[颅骨软化] ▲cranioclasis[碎颅术] ·-cyst-[囊] ▲cystomy[膀胱切开术] ▲dacryocyst[泪囊] ·-cyte-[细胞] ▲lymphocyte[淋巴细胞] ▲cytolysis[细胞溶解] ·de-[除去] ▲detoxication[解毒] ·dento[牙] ▲dentistry[牙科学] ▲dentalgia[牙痛] ·-derm-[皮肤] ▲epiderm[表皮] ▲dermatology[皮肤病学] ▲dermoplasty[皮肤成形术] ·dextro-[右] ▲dextrocardia[右位心] ▲dexiotropic[右旋的] ·dis-[分离] ▲discission[分离术] ▲disinfection[消毒法] ·duodeno-[十二指肠] ▲duodenitis[十二指肠炎] ▲duodenostomy[十二指肠造口术] ·-dynia[痛] ▲acrodynia[肢体痛] ▲urethrodynia[尿道痛] ·dys-[异常] ▲dysfunction[功能不良] ▲dyshormonism[内分泌障碍] ▲dysuria[排尿困难] ·-ectasis[扩张] ▲gastroectasis[胃扩张] ▲aerenterectasia[肠胀气] ▲bronchiectasia[支气管扩张] ·-ectomy[切除术] ▲appendectomy[阑尾切除术] ▲lipectomy[脂肪切除术] ·-edema[水肿] ▲encephaledema[脑水肿] ▲myxedema[粘液性水肿] ·-emesia[呕] ▲hematemesia[呕血] ▲helminthemesia[吐虫] ·encephalo-[脑] ▲encephaloma[脑瘤] ▲encephaledema[脑水肿] ·endo-[内] ▲endocarditis[心内膜炎] ▲endoscope[内窥镜] ·entero-[肠] ▲enteritis[肠炎] ▲enterovirus[肠病毒] ·epi-[上，外] ▲epigastrium[上腹部] ·erythro-[红] ▲erythromycin[红霉素] ▲erythroderma[红皮病] ·esophago-[食管] ▲esophagoscope[食管镜] ▲esophagitis[食管炎] ·extra-[……外] ▲extracellular[细胞外的] ▲extrasystole[额外收缩]
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