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] ·facio-[面] ▲facioplegia[面瘫] ▲facioplasty[面部成形术] ·-fast[耐] ▲acid-fast[抗酸的] ▲uviofast[耐紫外线] ·febri-[热] ▲febricula[低热] ▲febrifacient[致热的] ·feti-[胎儿] ▲feticulture[妊娠期卫生] ▲fetometry[胎儿测量法] ·fibro-[纤维] ▲fibroblast[成纤维细胞] ▲fibrosis[纤维化] ·fore-[前] ▲forebrain[前脑] ▲forehead[前额] ·-form[形状] ▲oviform[卵形的] ▲granuliform[颗粒状的] ·fungi-[真菌，霉菌] ▲fungicide[杀真菌剂] ▲fungistasis[制霉菌作用] ·gastro-[胃] ▲gastroptosis[胃下垂] ▲gastroenteritis[胃肠炎] ▲gastroscopy[胃镜检查] ▲gastratrophy[胃萎缩] ·-gen [原，剂] ▲glycogen[糖原] ▲pathogen[病原体] ▲androgen[雄激素] ▲Estrogen[雌激素] ·-genic[……性] ▲cardiogenic[心源性的] ▲allergenic[变应反应] ·giganto-[巨大] ▲gigantocyte[巨红细胞] ▲gigantism[巨大症] ·gingivo-[牙龈] ▲gingivitis[牙龈炎] ▲gingivostomatitis[牙龈口腔炎] ·glosso-[舌] ▲glossoplegia[舌瘫痪] ·gluco-[糖] ▲glucoprotein[糖蛋白] ▲glucocorticoid[糖皮质激素] ·glyco-[糖] ▲glycogen[糖原] ▲glycouria[糖尿] ·-grade[级，度] ▲centigrade[摄氏温度计] ▲retrograde[逆行性] ·-gram[克，图] ▲microgram[微克] ▲electroencephalogram[脑电图] ·-graph(y)[……仪（法）] ▲electrocardiogram[心电图] ▲bronchography[支气管造影术] ·gyneco-[妇女] ▲gynecology[妇科学] ▲gynecopathy[妇科病] ·hemo(hemato)-[血] ▲hemoglobin[血红蛋白] ▲ 4 回复：医学英语常用前后缀 hematoma[血肿] ·hemi-[半] ▲hemiplegia[偏瘫] ▲hemicrania[偏头病] ·hepato-[肝] ▲hepatitis[肝炎] ▲hepatocirrhosis[肝硬化] ▲hepatosplenomegaly[肝脾肿大] ·hidro-[汗] ▲hyperhidrosis[多汗症] ▲anhidrosis[无汗症] ·histo-[组织] ▲histology[组织学] ▲histomorphology[组织形态学] ·holo-[全] ▲holonarcosis[全麻] ▲holoenzyme[全酶] ·homo-[同] ▲homotype[同型] ▲homologue[同系物] ▲homoplasty[同种移植术] ·hydro-[水] ▲hydropericardium[心包积水] ▲hydrolysis [水解] ·hypr-[高] ▲hypercalcemia[高钙血症] ▲hyperthyroidism[甲亢] ·hypno-[睡眼] ▲hypnotics[安眠药] ▲hypnotherapy[催眠疗法] ·hypo-[低] ▲hypotension[低血压] ▲hypoglycemia[低血糖] ·hystero-[子宫] ▲hysterospasm[子宫痉挛] ▲hysteroptosis[子宫下垂] ·-ia[病] ▲melancholia[忧郁症] ▲pyrexia[发热] ·-iatrics[医学] ▲pediatrics[儿科学] ▲geriatrics[老年病学] ·-iatry[医学] ▲psychiatry[精神病学] ▲pediatry[儿科学] ·immuno-[免疫] ▲immunoglobulin[免疫球蛋白] ▲immunotherapy[免疫疗法] ·infra-[下] ▲infraorbital[眶下的] ▲infrared[红外线] ·inter-[间] ▲intervertebral[椎间的] ▲intercellular[细胞间的] ·intra-[内] ▲intravenous[静脉内的] ▲intracranial[颅内的] ▲intramuscular[肌肉内的] ·-ist[家] ▲pathologist[病理学家] ▲anatomist[解剖学家] ·-itis[炎症] ▲cellulitis[蜂窝织炎] ▲myocarditis[心肌炎] ·leuco (leuko)-[白] ▲leucorrhea[白带] ▲leukocytosis[白细胞增多] ▲leukemia[白血病] ·lipo-(脂) ▲lipotrophy[脂肪增多] ▲lipase[脂酶] ·-lith[结石] ▲cholelith[胆结石] ▲cholelithiasis[胆石症] ·-logy[学] ▲terminology[术语学] ▲Cardiology[心脏病学] ·lumbo-[腰] ▲lumbosacral[腰骶部的] ▲lumbago[腰背痛] ▲lumbodynia[腰痛] ·lympho-[淋巴] ▲lymphedema[淋巴水肿] ▲lymphocytopenia[淋巴细胞减少] ·-lysis(lytic)[松解，分解了] ▲aythrolysis[关节松解术] ▲spasmolytic[解痉的] ·macro-[大] ▲macrophage[巨噬细胞] ▲macromolecule[大分子] ·mal-[不良] ▲malnutrition[营养不良] ▲malfunction[功能不全] ·-megaly[巨大] ▲cardiomegaly[心扩大] ▲cephalomegaly[巨头畸形] ·meningo-[脑膜] ▲meningitis[脑膜炎] ▲meningocephalitis[脑膜脑炎] ·meno-[月经] ▲dysmenorrhea[痛经] ▲menopause[停经] ·-meter[表，计] ▲spirometer[肺活量计] ▲pyrometer[高温表] ·-metry[测量法] ▲iodometry[碘定量法] ·micro-[小] ▲micropump[微泵] ▲microliter[微升] ·mono-[单-] ▲mononucleosis[单核细胞增多] ▲monomer[单体] ·multi-[多] ▲multinuclear[多核的] ▲multipara[经产妇] ·myelo-[髓] ▲myelocele[脊髓膨出] ▲myelocyte[髓细胞] ·myo-[肌] ▲myocarditis[心肌炎] ▲myofibroma[肌纤维瘤] ·naso-[鼻] ▲nasoscope[鼻镜] ▲nasitis[鼻炎] ·neo-[新] ▲neoplasm[瘤] ▲neomycin[新霉素] ·nephro-[肾] ▲nephropathy[肾病] ▲nephrosclerosis[肾硬变] ·neuro-[神经] ▲neuroma[神经瘤] ▲neurodermatitis[神经性皮炎] ·non-[非] ▲non-electrolyte[非电解质] ▲nonfetal[非致命的] ·nulli-[无] ▲nullipara[未产妇] ▲nulligravida[未孕妇] ·nutri-[营养] ▲nutrition[营养] ▲nutrology[营养学] ·oculo-[眼] ▲oculist[眼科医生] ▲oculus dexter[右眼] ▲oculus sinister[左眼] 5 回复：医学英语常用前后缀 ·oligo-[少] ▲oligophrenia[智力发育不全] ▲oliguria[少尿] ·-oma[肿瘤] ▲adenoma[腺瘤] ▲osteoma[骨瘤] ·onco-[肿瘤] ▲oncology[肿瘤学] ▲oncogene[癌基因] ·ophthalmo-[眼] ▲ophthalmocele[眼球突出] ▲ophthalmoplegia[眼肌麻痹] ·-osis[病] ▲cirrhosis[肝硬化] ▲mycosis[霉菌病] ·osteo-[骨] ▲osteomalacia[骨软化] ▲osteoarthritis[骨关节炎] ·oto-[耳] ▲otolith[耳石] ▲otoplasty[耳成形术] ▲otopyosis[耳化脓] ·pan-[全] ▲panimmunity[多种免疫] ▲pantalgia[全身痛] ▲pantatrophia[全身营养不良] ·-para[产妇] ▲primipara[初产妇] ▲nullipara[未产妇] ·-pathy[病] ▲dermatopathy[皮肤病] ▲Cardiomyopathy[心肌病] ·pedia-[儿童] ▲pediatrician[儿科医师] ▲pediatrics[儿科学] ·-penia[减少] ▲leucopenia[白细胞减少] ▲thrombopenia[血小板减少] ·per-[经] ▲percutaneous[经皮肤的] ·peri-[周围] ▲pericarditis[心包炎] ▲perianal[肛周的] ·pharmaco-[药] ▲pharmacokinetics[药代动力学] ▲physicochemistry[药典] ·physio-[物理 ▲physiotheraphy[理疗] ▲physicochemistry[物理化学] ·-plasty[成形术] ▲angioplasty[血管成形术] ▲homoplasty[同种移植] ▲gastroplasty[胃成形术] ·-plegia[瘫] ▲paraplegia[截瘫] ▲hemiplegia[偏瘫] ·pleuro-[胸膜] ▲pleuritis[胸膜炎] ▲pleurocentesis[胸腔穿刺术] ·-pnea[呼吸] ▲orthopnea[端坐呼吸] ▲tachypnea[呼吸急促] ·pneumo-[气，肺] ▲pneumothorax[气胸] ▲pneumococcus[肺炎球菌] ·poly-[多] ▲polyuria[多尿] ▲polycholia[胆汗过多] ·post-[后] ▲postpartum[产后] ▲postoperation[术后] ·pre-[前] ▲premenopause[绝经前期] ▲premature[早搏] ▲preload[前负荷] ·pseudo-[假] ▲psudohypertrophy[假性肥大] ▲psudomembranous[假膜的] ·psycho-[精神，心理] ▲psychology[心理学] ▲psychiatry[精神病学] ·-ptosis[下垂] ▲nephroptosis[肾下垂] ▲hysteroptosis[子宫下垂] ·-ptysis[咯] ▲pyoptysis[咯脓] ▲hemoptysis[咯血] ·pyo-[脓] ▲pyorrhea[溢脓] ▲pyosis[化脓] ·radio-[放射] ▲radiotherapy[放疗] ▲radiology[放射学] ·recto-[直肠] ▲rectitis[直肠炎] ▲rectectomy[直肠切除术] ·retino-[视网膜] ▲retinitis[视网膜炎] ▲retinodialysis[视网膜分离] ·rhino-[鼻] ▲rhinitis[鼻炎] ▲rhinorrhea[鼻漏] ·-rrhagia[出血] ▲gastorrhagia[胃出血] ▲hemorrhage[出血] ▲pneumorrhagia[肺出血] ·-rrhaphy[缝合术] ▲neurorrhaphy[神经缝合术] ▲Vasorrhaphy[输卵管缝合术] ·-rrhea[流出] ▲diarrhea[腹泻] ▲menorrhea[月经] ·schisto-[裂] ▲schistosomiasis[血吸虫病] ▲schistoglossia[舌裂] ·scirrho-[硬] ▲scirrhosarca[硬皮病] ▲scirrhoma[硬癌] ·sclero-[硬] ▲scleroderma[硬皮病] ▲sclerometer[硬度计] ·-scope(y)[镜，检查] ▲stethoscope[听诊器] ▲otoscope[耳镜] ▲proctoscopy[直肠镜检查法] ·semi-[半] ▲semicoma[半昏迷] ▲semiliquid[半流汁] ·spondylo-[脊椎] ▲spondylopathy[脊椎病] ▲spondylitis[脊椎炎] ·-stomy[造口术] ▲colostomy[结肠造口术] ▲ilecolostomy[回结肠吻合术] ·sub-[下，亚] ▲subacute[亚急性] ▲subabdominal[下腹部的] ·super-[在…上] ▲superficial[浅的] ▲superoxide[超氧化物] ·supra-[上] ▲supraventricular[室上性的] ▲suprarenalism[肾上腺机能亢进] ·tachy-[快] ▲tachycardia[心动过速] ▲tachypnea[呼吸急促] ·-therapy[治疗] ▲massotherapy[按摩治疗] ▲pharmacotherapy[药物治疗] ·thermo-[热] ▲thermometer[温度计] ▲thermatology[热疗学] ·thrombo-[血栓，血小板] ▲thrombolysis[溶栓] ▲thrombocytopenia[血小板减少症] ▲thrombosis[血] ·-tomy[切开术] ▲tracheotomy[气管切开术] ▲ovariotomy[卵巢切开术] ·tracheo-[气管] ▲tracheoscope[气管镜] ▲tracheorrhagia[气管出血] ·trans-[经，转移] ▲transurethral[经尿道] ▲transfusion[输血] ·-trophy[营养] ▲dystrophy[营养不良] ▲atrophy[萎缩] ·ultra-[超过] ▲ultraviolet[紫外线] ▲ultrasound[超声] ·utero-[子宫] ▲uteroscope[子宫镜] ▲uterotonic[宫缩剂] ·vaso-[血管] ▲vasomotion[血管舒缩] ▲Vasodilator[血管扩张剂] 6 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] ·facio-[面] ▲facioplegia[面瘫] ▲facioplasty[面部成形术] ·-fast[耐] ▲acid-fast[抗酸的] ▲uviofast[耐紫外线] ·febri-[热] ▲febricula[低热] ▲febrifacient[致热的] ·feti-[胎儿] ▲feticulture[妊娠期卫生] ▲fetometry[胎儿测量法] ·fibro-[纤维] ▲fibroblast[成纤维细胞] 7 回复：医学英语常用前后缀 ▲fibrosis[纤维化] ·fore-[前] ▲forebrain[前脑] ▲forehead[前额] ·-form[形状] ▲oviform[卵形的] ▲granuliform[颗粒状的] ·fungi-[真菌，霉菌] ▲fungicide[杀真菌剂] ▲fungistasis[制霉菌作用] ·gastro-[胃] ▲gastroptosis[胃下垂] ▲gastroenteritis[胃肠炎] ▲gastroscopy[胃镜检查] ▲gastratrophy[胃萎缩] ·-gen [原，剂] ▲glycogen[糖原] ▲pathogen[病原体] ▲androgen[雄激素] ▲Estrogen[雌激素] ·-genic[……性] ▲cardiogenic[心源性的] ▲allergenic[变应反应] ·giganto-[巨大] ▲gigantocyte[巨红细胞] ▲gigantism[巨大症] ·gingivo-[牙龈] ▲gingivitis[牙龈炎] ▲gingivostomatitis[牙龈口腔炎] ·glosso-[舌] ▲glossoplegia[舌瘫痪] ·gluco-[糖] ▲glucoprotein[糖蛋白] ▲glucocorticoid[糖皮质激素] ·glyco-[糖] ▲glycogen[糖原] ▲glycouria[糖尿] ·-grade[级，度] ▲centigrade[摄氏温度计] ▲retrograde[逆行性] ·-gram[克，图] ▲microgram[微克] ▲electroencephalogram[脑电图] ·-graph(y)[……仪（法）] ▲electrocardiogram[心电图] ▲bronchography[支气管造影术] ·gyneco-[妇女] ▲gynecology[妇科学] ▲gynecopathy[妇科病] ·hemo(hemato)-[血] ▲hemoglobin[血红蛋白] ▲hematoma[血肿] ·hemi-[半] ▲hemiplegia[偏瘫] ▲hemicrania[偏头病] ·hepato-[肝] ▲hepatitis[肝炎] ▲hepatocirrhosis[肝硬化] ▲hepatosplenomegaly[肝脾肿大] ·hidro-[汗] ▲hyperhidrosis[多汗症] ▲anhidrosis[无汗症] ·histo-[组织] ▲histology[组织学] ▲histomorphology[组织形态学] ·holo-[全] ▲holonarcosis[全麻] ▲holoenzyme[全酶] ·homo-[同] ▲homotype[同型] ▲homologue[同系物] ▲homoplasty[同种移植术] ·hydro-[水] ▲hydropericardium[心包积水] ▲hydrolysis [水解] ·hypr-[高] ▲hypercalcemia[高钙血症] ▲hyperthyroidism[甲亢] ·hypno-[睡眼] ▲hypnotics[安眠药] ▲hypnotherapy[催眠疗法] ·hypo-[低] ▲hypotension[低血压] ▲hypoglycemia[低血糖] ·hystero-[子宫] ▲hysterospasm[子宫痉挛] ▲hysteroptosis[子宫下垂] ·-ia[病] ▲melancholia[忧郁症] ▲pyrexia[发热] ·-iatrics[医学] ▲pediatrics[儿科学] ▲geriatrics[老年病学] ·-iatry[医学] ▲psychiatry[精神病学] ▲pediatry[儿科学] ·immuno-[免疫] ▲immunoglobulin[免疫球蛋白] ▲immunotherapy[免疫疗法] ·infra-[下] ▲infraorbital[眶下的] ▲infrared[红外线] ·inter-[间] ▲intervertebral[椎间的] ▲intercellular[细胞间的] ·intra-[内] ▲intravenous[静脉内的] ▲intracranial[颅内的] ▲intramuscular[肌肉内的] ·-ist[家] ▲pathologist[病理学家] ▲anatomist[解剖学家] ·-itis[炎症] ▲cellulitis[蜂窝织炎] ▲myocarditis[心肌炎] ·leuco (leuko)-[白] ▲leucorrhea[白带] ▲leukocytosis[白细胞增多] ▲leukemia[白血病] ·lipo-(脂) ▲lipotrophy[脂肪增多] ▲lipase[脂酶] ·-lith[结石] ▲cholelith[胆结石] ▲cholelithiasis[胆石症] ·-logy[学] ▲terminology[术语学] ▲Cardiology[心脏病学] ·lumbo-[腰] ▲lumbosacral[腰骶部的] ▲lumbago[腰背痛] ▲lumbodynia[腰痛] ·lympho-[淋巴] ▲lymphedema[淋巴水肿] ▲lymphocytopenia[淋巴细胞减少] ·-lysis(lytic)[松解，分解了] ▲aythrolysis[关节松解术] ▲spasmolytic[解痉的] ·macro-[大] ▲macrophage[巨噬细胞] ▲macromolecule[大分子] ·mal-[不良] ▲malnutrition[营养不良] ▲malfunction[功能不全] ·-megaly[巨大] ▲cardiomegaly[心扩大] ▲cephalomegaly[巨头畸形] ·meningo-[脑膜] ▲meningitis[脑膜炎] ▲meningocephalitis[脑膜脑炎] ·meno-[月经] ▲dysmenorrhea[痛经] ▲menopause[停经] ·-meter[表，计] ▲spirometer[肺活量计] ▲pyrometer[高温表] ·-metry[测量法] ▲iodometry[碘定量法] ·micro-[小] ▲micropump[微泵] ▲microliter[微升] ·mono-[单-] ▲mononucleosis[单核细胞增多] ▲monomer[单体] ·multi-[多] ▲multinuclear[多核的] ▲multipara[经产妇] ·myelo-[髓] ▲myelocele[脊髓膨出] ▲myelocyte[髓细胞] ·myo-[肌] ▲myocarditis[心肌炎] ▲myofibroma[肌纤维瘤] ·naso-[鼻] ▲nasoscope[鼻镜] ▲nasitis[鼻炎] ·neo-[新] ▲neoplasm[瘤] ▲neomycin[新霉素] ·nephro-[肾] ▲nephropathy[肾病] ▲nephrosclerosis[肾硬变] ·neuro-[神经] ▲neuroma[神经瘤] ▲neurodermatitis[神经性皮炎] ·non-[非] ▲non-electrolyte[非电解质] ▲nonfetal[非致命的] ·nulli-[无] ▲nullipara[未产妇] ▲nulligravida[未孕妇] ·nutri-[营养] ▲nutrition[营养] ▲nutrology[营养学] ·oculo-[眼] ▲oculist[眼科医生] ▲oculus dexter[右眼] ▲oculus sinister[左眼]
医学英语缩写一览表
医学英语缩写一览表 ·aa.-of each[各] ·Ab.-antibody[抗体] ·abd.-abdomen[腹部] ·ABG-arterial blood gas[动脉血气] ·abn.-abnormal[异常] ·ABp-arterial blood pressure[动脉压] ·Abs.-absent[无] ·abstr.-abstract[摘要] ·a.c.-before meals[饭前] ·Ach.-actylcholine[乙酰胆碱] ·ACH.-adrenal cortical hormone[肾上腺皮质激素] ·ACT.-active coagulative time[活化凝血时间] ·ACTH.-adrenocorticotripic[促肾上腺皮质激素] ·ad.(add.)-adde[加] ·ad effect.-ad effectum [直到有效] ·ADH.-antidiuretic hormone[抗利尿激素] ·ad lib-at liesure[随意] ·adm.(admin)-adminstration[给药] ·ad us est.-for external use[外用] ·af.-atrial fibrillation[房颤] ·aF.-atrial flutter[房扑] ·A/G ratio.-albumin-globulin ratio[白-球蛋白比] ·AIDS.-acquired immune deficiency syndrome[爱滋病] ·al.-left ear[左耳] ·alb.-albumin[白蛋白] ·AM.-before noon[上午] ·amb.-ambulance[救护车] ·amp.(ampul)-ampoule[安瓿] ·ANA.-anesthesia[麻醉] ·anal.-analgesic[镇痛药] ·ap.-before dinner[饭前] ·appr.(approx.)-approximately [大约] ·AR.-aortic regurgitation[主闭] ·AS.-aortic stenosis[主狭] ·ASA.-aspirin[阿斯匹林] ·ASD.-atrial septal defect[房缺] ·AST.-aspartate transaminase[谷草转氨酶] ·atm.(atmos.)-atomsphere[大气压] ·ATS.-antitetanic serum[抗破伤风血清] ·av.-average[平均] ·Ba.-Barium[钡] ·BBT.-basal body temperature[基础体温] ·BCG.-bacille Calmette- Guerin[卡介苗] ·biblio.-biliography[参考文献] ·bid.-twice a day[每日二次] ·b.m.-basal metabolism[基础代谢] ·Bp.-blood pressure[血压] ·bpm-baets per minute[次/分] ·BS.-blood sugar[血糖] ·BW.-body weight[体重] ·C.- centigrade[摄氏温度计] ·CA.-carcinoma[癌] ·Cal.-cancer[癌] ·Cal. – calorie[卡] ·Cap. – capsule[囊] ·C.B.C-complete blood count[血常规] ·CC.-chief complaint[主诉] ·CC. list.-critical condition list[病危通知单] ·CCU.- Coronary care unit[冠心病监护室] ·CD.-caesarean delivered[剖腹产] ·CDC.-calculated date of confinement[预产期] ·CEA.-carcinoembryonic antigen[癌胚抗原] ·CG.-control group[对照组] ·CK.-creatine kinase[肌酸激酶] ·Cl.-centilitre[毫开] ·cm.-centimetre[毫米] ·CNS.-central nervous system[中枢神经系统] ·Co.-compound[复方] ·contra.-contraindicated[禁忌] ·CT.- computerized tomography[计算机断层扫描] ·C.V-curriculum vitae[简历] ·DBp-diastolic blood pressure[舒张压] ·DD.- differential diagnosis[鉴别诊断] ·dept.-department[科] ·diag.-diagonsis[诊断] ·DIC-disseminate intravascular coagulation[弥漫性血管内凝血] ·dl.-deciliter[分升] ·DM.-diabetic mellitus[糖尿病] ·DM.-diastolic murmur[舒张期杂音] ·D.O.A-dead on arrival[到达时已死亡] ·DOB.-date of birth[出生日期] ·Dr.-doctor[医生] ·DIW.-dextrose in water[葡萄糖液] ·D-5-W,-5% dextrose in water[5%葡萄糖液] ·DU-duodenal ulcer[十二指肠溃疡] ·ECG.(EKG.)- electrocardiograph[心电图] ·ECHO .-echogram[超声] ·EDD.(EDC)-expected date of delivery (confinement)[预产期] ·ENT. – ears, nose and throat[五官科] ·EMG. – electromyogram[肌电图] ·ER. – emergency room[急诊室] ·et al.-and elsewhere[等等] ·etc. – and so forth[等等] ·F.(Fahr.)-Fahrenheit [华氏] ·F- Female[女性] ·F.B.S.- fasting blood sugar[空腹血糖] ·FDP.-fibrinogen degradation products[纤维蛋白原降解产物] ·FFA. – free fatty acid[游离脂肪酸] ·FUO. – fever of unknown origin[不明原因发热] ·FX. – fracture [骨折] ·GH. – growth hormone[生长素] ·GI.- gastrointestinal[消化] ·GITS. – gastrointestinal therapy system[胃肠治疗系统] ·gtt. – drops[滴] ·GU.- gastric ulcer[胃溃疡] ·Hb. – hemoglobin[血红蛋白] ·HBp.-high blood pressure[高血压] ·HCG. – human choroionic gonadotropic hormone[人绒毛膜促性腺激素] ·HDL.- high density lipoprotein[高密度脂蛋白] ·HR.-heart rate[心率] ·ht.-height[身高] ·HTN.-hypertension[高血压] ·Hx.-history [病历] ·Hypo.-hypodermic injection[皮下注射] ·IABP.-intra – aortic balloon pacing[主动脉内囊反搏] ·I/O.-intake and output [进出量] ·ICU. – intensive care unit[重症监护病房] ·ie. – that is [即] ·Ig. – immunoglobulin[免疫球蛋白] ·Im. – iutramuscular[肌内的] ·INH.- inhalation[吸入] ·INH.- isoniazid[异烟肼] ·Inj.- injection[注射] ·Int.- intern[实习生] ·IP.- in-patient[住院病入] ·Iu.- international unit[国防单位] ·IV.-intravenously[静脉内] ·J.- joule[焦耳] ·K.U.B- Kidney,ureter and bladder[肾、输尿管和膀胱] ·LBp.-low blood pressure [低血压] ·LC. – laparoscopic cholecystectomy[腹腔镜胆囊切除术] ·LDL.-Low density lipoprotein[低密度脂蛋白] ·Liq. – liquid[液体] ·LMP.- last menstrual period[未次月经] ·LP. –lumbar puncture[腰穿] ·M. –male[男性] ·MCD.-mean corpuscular diameter[平均红细胞直径] ·MCH.-mean corpuscular hemoglobin[平均红细胞血红蛋白量] ·MCHC.-mean corpuscular hemoglobin concentration[平均红细胞血红蛋白浓度] ·MCV.-mean corpuscular volume[平均红细胞体积] ·MI.-myocardial infarction[心梗] ·min.-minute[分] ·mixt。 –mixture[合剂] ·mmHg.- millimeters of mercury[毫米汞柱] ·MRI.- magnetic resonance image[核磁共振] ·MS.- mitral stenosis[二尖瓣狭窄] ·N/V.-nausea and vomiting[恶心呕吐] ·N.B – note bene [注意] ·NE.- norepinephrine [去甲肾上腺炎] ·neg.- negative[阴性的] ·NIDDM.- non-insulin-dependent diabetis mellitus[II型糖尿病] ·norm.- normal[正常的] ·NPN.-non-protein nitrogen[非蛋白氮] ·NPO.- non-peros[禁食] ·NS. –normal saline[生理盐水] ·OB.- obstetrics [产科学] ·OGTT.- oral glucose tolerance test[口服糖耐量试验] ·OP.- out-patient[门诊病人] ·OPC.- out-patient clinic[门诊] ·OR.- operating room[手术室] ·OT. – old tuberculin[旧结核菌素] ·P-pulse[脉搏] ·P.C.- post cibum [饭后] ·PE. (Px.)- physical examination[体检] ·PG. – prostaglandin[前列腺素] ·PH. – past history [过去史] ·PHI. – present history illness[现病史] ·PM.- post meridiem[下午] ·Post-op.- postoperation[术后] ·pre-op.- preoperation[术前] ·priv. – private[私人的] ·prn.-pro re nata[必要时] ·prog.- prognosis[预后] ·P.S. – postscript[附言] ·Psy.- psychiatry[精神病学] ·psychol. – psychology[心理学] ·PT. – physical therapy[物理疗法] ·PT.- prothrombin time[凝血酶原时间] ·qd.- quaque die [每日一次] ·qid.-quater in die [每日四次] ·qn.-quaque nocte[每晚] ·RBC.-red blood count[红细胞计数] ·ref.-reference[参考文献] ·RHD.-Rheumatic heart disease[风心病] ·RI.-regular insulin[正规胰岛素] ·rout.-routin[常规] ·RT.-radiotherapy[放射治疗] ·SBE –subacute bacterial endocarditis[亚急性细菌性心内膜炎] ·Seq.-sequela[后遗症] ·sex.-sexual[性别的] ·sig.-signa[标明用法] ·SK.-streptokinase[链激酶] ·SLE.-sgstemic lupus erythematosus[系统性红斑狼疮] ·SM.-systolic murmur[收缩期杂音] ·SR.-sinus rhythm[窦性节律] ·SSS.-sick sinus syndrome[病窦综合征] ·ST.- skin test[皮试] ·stat.- at once[立即] ·Sx.- symptom or sign[症状或体征] ·Syr.- syrup[糖浆] ·Tab.- stablet[片剂] ·TAT.- toxin-antitoxin[毒素抗毒素] ·TB.-tuberculosis[结核] ·tid.- three times daily[每日三次] ·TSH.- thyroid-stimulating hormone[促甲状腺激素] ·us.- ultrasound[超声] ·VIP.- very important person[贵宾] ·Vit.- vitamine[维生素] ·VSD.- ventricular septal defect[室缺] ·VMA.- hydroxymandelic acid[香草杏仁酸] ·WBC.- white blood cell[白细胞] ·Wt.- weight[体重] ·Y/O.- years old [岁]
住院文书格式
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]
医学英语的特征
① 特殊的单复数(单数→复数) ·a→ae ▲aortae-aortae[主动脉] ▲pleura-pleurae[胸膜] ·us→i ▲coccus-cocci[球菌] ▲bacillus-bacilli[杆菌] ·um→a ▲serum-sera[血清] ▲bacterium-bactera[细菌] ·on→a ▲phenomenon-phenomena[现象] ▲criterion-criteria[标准] ·x→ces ▲cortex-cortices[皮质] ▲appendix-appendices[阑尾] ▲thorax-thoraces[胸廓] ·x→ges ▲pharynx-pharynges[咽] ▲larynx-larynges[喉] ·is→es ▲crisis-crises[危象] ▲analysis-analyses[分析] ·ma→mata ▲trauma-traumata[创伤] ▲hemotoma-hemotomata[血肿] ·men→mina ▲lumen-lumina[腔] ▲abdomen-abdomina[腹] 2、字母可互通使用 ·ae-e ▲haemorrhage-hemorrhage[出血] ▲aetiology-etiology[病因] ·oe-e ▲oedema-edema[水肿] ▲oesophagus-esophagus[食管] ·ou-u ▲oulitis-ulitis[牙龈炎] ▲ouroscopy-uroscopy[尿检] ·ph-f ▲sulphate-sulfate[硫酸盐] ▲sulphonamide-sulfonamide[磺胺] ·k-c ▲EKG-ECG[心电图] ▲leukocyte-leucocyte[白细胞] ▲Katabolism-catabolism[分解代谢] ·y-i ▲syrup-sirup[糖浆] 3、英美的不同拼写形式(英-美) ·our(英)-or(美) ▲colour-color[颜色] ▲tumour-tumor[肿瘤] ·re-er ▲centre-center[中心] ▲metre-meter[米] ·yes-yze ▲analyse-analyze[分析] ▲paralyse-paralyze[瘫痪] ·xion-ction ▲connexion-connection[连接] ▲reflexion-reflection[反射] ·mme-m ▲gramme-gram[克] ·ogue-og ▲dialogue-dialog[对话] ▲catalogue-catalog[目录] ·c-k ▲disc-disk[软盘] ▲sceptic-skeptic[怀疑论者] 4、词根交替现象 ·mouth[口]-oral[口的] ·tooth[牙齿]-dental[牙齿的] ·tongue[舌]-lingual[舌的] ·ear[耳]-aural[耳的] ·nose[鼻]-nasal[鼻的] ·eye[眼]-ophthalmic[眼的] ·skin[皮肤]-dermal[皮肤的] ·heart [心]-cardiac[心脏的] ·liver[肝]-hepatic[肝的] ·stomach[胃]-gastric[胃的] ·lung[肺]-pulmonary[肺的] ·kideny[肾]-renal[肾的] ·neck[颈]-cervical[颈的] ·chest[胸]-thoracic[胸的] ·brain[脑]-cerebral[脑的] ·nerve[神经]-neural[神经的] ·rib[肋骨]-costal[肋骨的] ·mother[母]-maternal[母亲的] ·heat[热]-thermal[热的] ·bone[骨]-bony[骨的] ·virus[病毒]-viral[病毒的] ·saliva[唾液]-salivary[唾液的] ·respiration[呼吸]-respiratory[呼吸的] ·joint[关节]-arthritis[关节炎] ·kidney[肾]-nephritis[肾炎] ·nerve[神经]-neuritis[神经炎] ·lioer[肝]-hepatitis[肝炎] ·brain[脑]-encephalitis[脑炎] ·stomache[胃]-gastritis[胃炎] ·artery[动脉]-arteritis[动脉炎] ·bronchus[支气管]-bronchitis[支气管炎] ·heart[心]-cardiology[心脏病学] ·eye[眼]-ophthalmology[眼科学] ·cell[细胞]-cytology[细胞学] ·tumor[肿瘤]-oncology[肿瘤学] ·disease[病]-pathology[病理学] ·drug[药]-pharmocology[药理学] ·parasite[寄生虫]-parasitology[寄生虫学] ·bacterium[细菌]-bacteriology[细菌学] ·cell[细胸]-cyto-[细胞] ·blood[血]-hemo-[血] 5、常用拉丁短语 ·ad arbitrium[随意地] ·ad decubitum[临睡时] ·ad effectum[直至有效] ·ad interim[暂时] ·ad libitum（ad lib）[随意] ·ad usum externum[外用] ·ad usum internum[内服] ·ante caenam[晚饭前] ·ante cibum[饭前] ·ante horam decubitus[睡前] ·ante jentaculum[早饭前] ·ante meridiem(A.M)[上午] ·bis in die(B.i.d)[每天二次] ·curriculum vitae (C.V)[简历] ·et al (et alia)[等等] ·exmpli gratia (e.g)[例如] ·id est (i.e)[即] ·in brevi[简言之] ·in situ[原位] ·in vitro[体外] ·in vivo[体内] ·locus in quo[现象] ·note bene(N.B)[注意] ·per annum[每年] ·per centum (percent)[百分之……] ·per diem[每日] ·per mensem[每月] ·per os (p.o)[经口] ·per rectum[经直肠] ·post meridiem （P.M）[下午] ·post mortem[死后] ·post partum[产后] ·post scriptum(P.S)[附言] ·pro dosi[一次量] ·pro et contra (pro et con)[赞成和反对] ·pro re nata (p.r.n)[必要时] ·quaque die (q.d)[每天一次] ·quaque nocte (q.n)[每晚一次] ·quaque quarta hora(q.4h)[每4小时1次] ·quaque secundo die(q.o.d)[每二天一次] ·ter in die (t.i.d)[每天三次] ·ut infra[如下所述] ·ut supra[如上所述] ·vice versa[反之亦然] ·vide infra[参见下文] ·vide supra[参见前文]
