作為一名合格的醫生，我們在拯救病人的同時，還要掌握一些我們專業的英語知識。這樣，我們可以看懂一些外文文獻，然后可以學到更多的知識。很多醫生認為醫學相關的英語比較難，不知道從何下手。今天小編就為大家總結了一些很重要的詞匯，大家可以先背誦一下。

1、 抗生素醫囑[Antibiotic order]
·Prophylaxis [預防性用藥] Duration of oder[用藥時間] 24hr
Procedure[操作，手術]
·Empiric theraphy [經驗性治療]
Suspected site and organism[懷疑感染的部位和致病菌] 72hr
Cultures ordered[是否做培養]
·Documented infection[明確感染]
Site and organism[部位和致病菌] 5days
·Other[其他]
Explanation required [解釋理由] 24hr
·Antibiotic allergies[何種抗生素過敏]
No known allergy [無已知的過敏]
·Drug+dose+Route+frequency[藥名+劑量+途徑+次數]

2、醫囑首頁[Admission / transfer]

·Admit / transfer to [收入或轉入]
·Resident [住院醫師] Attending[主治醫師]
·Condition [病情]
·Diagnosis[診斷]
·Diet [飲食]
·Acitivity [活動]
·Vital signs[測生命體征]
·I / O [記進出量]
·Allergies[過敏]

3、住院病歷[case history]

·Identification [病人一般情況]
Name[性名]
Sex[性別]
Age [年齡]
Marriage[婚姻]
Person to notify and phone No.[聯系人及電話]
Race[民族]
I.D.No.[身份證]
Admission date[入院日期]
Source of history[病史提供者]
Reliability of history[可靠程度]
Medical record No[病歷號]
Business phone No.[工作單位電話]
Home address and phone No.[家庭住地及電話]
·Chief complaint[主訴]
·History of present illness[現病史]
·Past History[過去史]
Surgical[外科]
Medical[內科]
Medications[用藥]
Allergies[過敏史]
Social History[社會史]
Habits[個人習慣]
Smoking[吸煙]
Family History[家族史]
Ob/Gyn History[ 婚姻/生育史]
Alcohol use[喝酒]
·Review of Aystems[系統回顧]
General[概況]
Eyes,Ears,Nose and throat[五官]
Pulmonary[呼吸]
Cardiovascular[心血管]
GI[消化]
GU[生殖、泌尿系統]
Musculoskeletal[肌肉骨骼]
Neurology[神經系統]
Endocrinology[內分泌系統]
Lymphatic/Hematologic[淋巴系統/血液系統]
·Physical Exam[體檢]
Vital Signs[生命體征]
P[脈博]
Bp[血壓]
R[呼吸]
T[溫度]
Height[身高]
Weight[體重]
General[概況]
HEENT[五官]
Neck[頸部]
Back/Chest[背部/胸部]
Breast[乳房]
Heart[心臟]
Heart rate[心率]
Heart rhythm[心律]
Heart Border[心界]
Murmur[雜音]
Abdomen[腹部]
Liver[肝]
Spleen[脾]
Rectal[直腸]
Genitalia[生殖系統]
Extremities[四肢]
Neurology[神經系統]
cranial nerves[顱神經]
sensation[感覺]
Motor[運動]
*Special P.E. on diseased organ system[專科情況]
*Radiographic Findings[放射]
*Laboratory Findings[化驗]
*Assessment[初步診斷與診斷依據]
*Summary[病史小結]
*Treatment Plan[治療計劃]

4、輸血申請單[Blood bank requisition form]

(1)reason for infusion[輸血原因]
▲紅細胞[packed red cells, wshed RBCs]:
*Hb<8.5 [血色素<8.5]
*>20% blood volume lost[>20%血容量丟失]
*cardio-pulmonary bypass with anticipated Hb<8[心肺分流術伴預計血色素

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