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最全的医学英语之NO.11、抗生素医嘱Antibiotic order Prophylaxis 预防性用药Duration of oder 用药时间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Cultures ordered 做培养Documented infection 明确感染Site and organism 部位和致病菌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 / transferAdmit / 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 生命体征I / O 记进出量Allergies 过敏3、住院病历case historyIdentification 病人一般情况Name 姓名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 Systems 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, washed RBCs:*Hb8.5 血色素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 units输血10单位以上者*platelet count 50103/l with active bleeding or surgery血小板5万伴活动性出血或手术者*Cardio-pulmonary bypass uith pl100103/l with octive bleeding心肺分流术伴血小板10万，活动性出血者*Platelet count 20103/l血板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 summaryPatient 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 recordPatient 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 determin