住院医生常用英语VIP免费

1、抗生素医嘱[Antibioticorder]·Prophylaxis[预防性用药]Durationofoder[用药时间]24hrProcedure[操作，手术]·Empirictheraphy[经验性治疗]Suspectedsiteandorganism[怀疑感染的部位和致病菌]72hrCulturesordered[是否做培养]·Documentedinfection[明确感染]Siteandorganism[部位和致病菌]5days·Other[其他]Explanationrequired[解释理由]24hr·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[测生命体征]·I/O[记进出量]·Allergies[过敏]3、住院病历[casehistory]·Identification[病人一般情况]Name[性名]Sex[性别]Age[年龄]Marriage[婚姻]Race[民族]I.D.No.[身份证]PersontonotifyandphoneNo.[联系人及电话]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]·ReviewofAystems[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,wshedRBCs]:*Hb<8.5[血色素<8.5]*>20%bloodvolumelost[>20%血容量丢失]*cardio-pulmonarybypasswithanticipatedHb<8[心肺分流术伴预计血色素<8]*chemotherapyorsurgerywithHb<10[血色素<10的化疗或手术者]▲全血[wholeblood]:massiveon-goingbloodloss[大量出血]▲血小板[platelets]:*massivebloodtransfusion>10units[输血10单位以上者]*plateletcount<50×103/μlwithactivebleedingorsurgery[血小板<5万伴活动性出血或手术者]*Cardio-pulmonarybypassuithpl<100×103/μlwithoctivebleeding[心肺分流术伴血小板<10万，活动性出血者]*Plateletcount<20×103/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]*bloodtransfusion>15units[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]DateofAdmi...