病例翻译常见术语分享

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 [经验性治疗] 
Suspected site and organism[怀疑感染的部位和致病菌] 
Cultures ordered[是否做培养] 

Documented infection[明确感染] 
Site and organism[部位和致病菌]
Other[其它] 

Explanation required [解释理由] 
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] 
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]l
P[脉博] 
Bp[血压] 
R[呼吸] 
T[温度] 

Height[身高] 
Weight[体重] 
General[概况]l
HEENT[五官] 
Neck[颈部] 

Back/Chest[背部/胸部] 
Breast[乳房] 
Heart[心脏]l
Heart rate[心率] 
Heart rhythm[心律] 
Heart Border[心界] 

Murmur[杂音] 
Abdomen[腹部]l
Liver[肝] 
Spleen[脾] 
Rectal[直肠] 
Genitalia[生殖系统]

Extremities[四肢]l
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 [心肺分流术伴预计血色素 ] 
*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/μlwith 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 orSurgery[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 withbleeding[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]l
Medical Record No.[病历号]l
Attending Physician[主治医生]l
Date of Admission[入院日期]l
Date of Discharge[出院日期]l
Principal Diagnosis[主要诊断]l

Secondary Diagnosis[次要诊断]l
Complications[并发症]l
Operation[手术名称]l
Reason for Admission[入院理由]l
Physical Findings[阳性体征]l
Lab/X-ray Findings[化验及放射报告]l

Hospital Course[住院诊治经过]l
Condition[出院状况]l
Disposition[出院去向]l
Medications[出院用药]l

Prognosis[预后]l
Special Instruction to the Patient(diet,physical activity)[出院指导（饮食，活动量）]l
Follow-up Care[随随访]l

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 the patient[与病人关系] 
previous admit date[上次住院日期] 
admitting physician [入院医生] 
attending physician [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] 
consultants [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) afteradmission[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]