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病历文书中常用基本用语的英文翻译

2013-12-21 作者：MedSci 来源：MedSci 我要评论2

Tags: 病历 翻译

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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] 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[其它]

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] ?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]