外科查房常用英語(yǔ)

1、1、抗生素醫(yī)囑Antibiotic order Prophylaxis 預(yù)防性用藥Duration of oder 用藥時(shí)間Procedure 操作，手術(shù)Empiric theraphy 經(jīng)驗(yàn)性治療Suspected site and organism 懷疑感染的部位和致病菌Cultures ordered 做培養(yǎng)Documented infection 明確感染Site and organism 部位和致病菌Explanation required 解釋理由Antibiotic allergies 何種抗生素過(guò)敏No known allergy 無(wú)已知的過(guò)敏Drug+dose+Route+f

2、requency藥名+劑量+途徑+次數(shù)2、醫(yī)囑首頁(yè)Admission / transferAdmit / transfer to 收入或轉(zhuǎn)入Resident 住院醫(yī)師Attending 主治醫(yī)師Condition 病情Diagnosis 診斷Diet 飲食Acitivity 活動(dòng)Vital signs 生命體征I / O 記進(jìn)出量Allergies 過(guò)敏3、住院病歷case historyIdentification 病人一般情況Name 姓名Sex 性別Age 年齡Marriage 婚姻Person to notify and phone No. 聯(lián)系人及電話Race 民族I.D.No. 身

3、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(hào)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(xiàn)病史Past History 過(guò)去史Surgical 外科 Medical 內(nèi)科Medications 用藥Allergies 過(guò)敏史Social History 社會(huì)史Habits 個(gè)人習(xí)慣Smoking 吸

4、煙Family History 家族史Ob/Gyn History 婚姻/生育史Alcohol use 喝酒Review of Systems 系統(tǒng)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(tǒng)Musculoskeletal 肌肉骨骼Neurology 神經(jīng)系統(tǒng)Endocrinology 內(nèi)分泌系統(tǒng)Lymphatic/Hematologic 淋巴系統(tǒng)/血液系統(tǒng)Physical Exam 體檢Vital Signs 生命體征P 脈博Bp 血壓R 呼吸T 溫度Height 身

5、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(tǒng)Extremities 四肢Neurology 神經(jīng)系統(tǒng)cranial nerves 顱神經(jīng)sensation 感覺(jué)Motor 運(yùn)動(dòng)*Special P.E. on diseased organ system專科情況*Radiographic Findings放射

6、*Laboratory Findings化驗(yàn)*Assessment初步診斷與診斷依據(jù)*Summary病史小結(jié)*Treatment Plan治療計(jì)劃4、輸血申請(qǐng)單Blood bank requisition form(1)reason for infusion輸血原因紅細(xì)胞packed red cells, washed 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(shù)伴預(yù)計(jì)血色素<8*chemoth

7、erapy or surgery with Hb <10血色素<10的化療或手術(shù)者全血whole blood:massive on-going blood loss大量出血血小板platelets:*massive blood transfusion >10 units輸血10單位以上者*platelet count <50×103/l with active bleeding or surgery血小板<5萬(wàn)伴活動(dòng)性出血或手術(shù)者*Cardio-pulmonary bypass uith pl<100×103/l with octive

8、bleeding心肺分流術(shù)伴血小板<10萬(wàn)，活動(dòng)性出血者*Platelet count <20×103/l血板<2萬(wàn)新鮮冰凍血漿fresh frozen plasma:*documented abnormal PT or PTT with bleeding or SurgeryPT、PTT異常的出血或手術(shù)病人*specific clotting factor deficiencies with bleeding/surgerg特殊凝血因子缺乏的出血/手術(shù)者*blood transfusion >15units輸血>15個(gè)單位*warfarin or an

9、tifibrinolytic therapy with bleeding華法令或溶栓治療后出血*DIC血管內(nèi)彌漫性凝血*Antithrombin III dficiency凝血酶III 缺乏(2)輸血要求request for blood components*patient blood group血型*Has the patient had transfusion or pregnancy in the past 3 months? 近3個(gè)月，病人是否輸過(guò)血或懷孕過(guò)？*Type and crossmatch血型和血交叉*Units or ml單位或毫升5、出院小結(jié)discharge summ

10、aryPatient Name病人姓名Medical Record No.病歷號(hào)Attending Physician主治醫(yī)生Date of Admission入院日期Date of Discharge出院日期Pirncipal Diagnosis主要診斷Secondary Diagnosis次要診斷Complications并發(fā)癥Operation手術(shù)名稱Reason for Admission入院理由Physical Findings陽(yáng)性體征Lab/X-ray Findings化驗(yàn)及放射報(bào)告Hospital Course住院診治經(jīng)過(guò)Condition出院狀況Disposition出院去向M

11、edications出院用藥Prognosis預(yù)后Special Instruction to the Patient(diet, physical activity)出院指導(dǎo)（飲食，活動(dòng)量）Follow-up Care隨隨訪6、住院/出院病歷首頁(yè)Admission/discharge recordPatient name病人姓名race種族address地址religion宗教medical service科別admit (discharge) date入院（出院）日期Length of stay 住院天數(shù)guarantor name 擔(dān)保人姓名next of kin or person t

12、o notify需通知的親屬姓名relation to patient與病人關(guān)系previous admit date上次住院日期admitting physician 入院醫(yī)生attending phgsician主治醫(yī)生admitting diagnosis入院診斷final (principal) diagnosis最終（主要）診斷secondary diagnosis次要診斷adverse reactions (complications)副作用（合并癥）incision type切口類型healing course愈合等級(jí)operative (non-operative) procedures手術(shù)（非手術(shù)）操作nosocomial infection院內(nèi)感染consutants會(huì)診Critical-No. of times搶救次數(shù)recovered-No. of times成功次數(shù)Diagnosis qualitative analysis診斷質(zhì)量OP.adm.and discharge Dx concur 門診入院與出院診斷符合率Clinical and pathological Dx concur臨床與病理診斷符合率Pre- and post-operative Dx concur 術(shù)