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1、精品醫(yī)學文檔 精品醫(yī)學文檔 精品醫(yī)學文檔 常用醫(yī)囑術語Medical orders(1)醫(yī)囑術語medical ordersAdmit/transfer to收入(轉入)Resident/attending住院(主診)醫(yī)師condition病情critical (Imminence)病危unstable不穩(wěn)定stable穩(wěn)定general (fair) 一般emergent急診Diagnosis診斷Diet飲食full (home) diet普食liquid (semi-liquid) diet流汁(半流汁)飲食soft diet軟食low salt and low fat diet低鹽低脂飲

2、食salt-free diet無鹽飲食low purine diet低嘌呤飲食low (non)-residue diet少(無)渣飲食light diet 清淡飲食high caloric diet高熱量飲食high protein (protein-rich) diet高蛋白飲食diabetic diet糖尿病飲食nephritic diet腎炎飲食nasal feeding鼻飼fasting (NPO, nothing by mouth)禁食NPO for 5 hours禁食5小時meal standard伙食標準activity活動absolute rest絕對臥床休息stay on

3、the bed (yest in bed)臥床休息Ad lib隨意活動In the ward 病房內(nèi)活動vital signs生命體征Q shift (q.6h)每班(每6小時)一次immoblization制動pressed by sand bag 沙袋壓迫I/O (intake and output)記出入量N/A (non-apply)不需要parameter: EKG(Bp,SaO2) monitor 其他:心電圖(血壓,氧飽和度)監(jiān) 護allergies過敏NKA (non-known allergies)無已知的過敏反應patient identification 病人身份4th

4、floor,room 5 ,bed 2(405-2)4樓5號房2床Med. Rec#病歷號medical orders醫(yī)囑on general routine護理常規(guī)on grade I (II, III) nuring careI (I、III)級護理morning (evening) care晨間(夜間)護理bedsore care褥瘡護理mouth (oral) care口腔護理CPT( chest physical treatment) 胸部物理治療O2 inhalation (2-4L/min)吸氧(2-4升/分)alcohol sponge bath酒精擦浴cold (hot) c

5、ompress冷(熱)敷wet (hydropathic) compress by MgSO4用硫酸鎂濕敷change position qh每小時更換一次體位gastric lavage with water用清水洗胃bladder irrigation 膀胱沖洗under water seal drainage of thorax胸腔水封瓶引流GI decompression 胃腸減壓keep warm保溫醫(yī).學 全在.線,提供 HYPERLINK / lower temperature by ice-cap冰帽降溫keep bowels open保持大便通暢keep the airway

6、 open保持氣道通暢retention catheterization留置導尿prevent from bedsore預防褥瘡on bedside isolation床邊隔離P.P sitz bath高錳酸鉀液坐浴raising the head (foot) of the bed抬高床頭(尾)pencillin (procaine, iodine) skin test青霉素(普魯卡因,碘)皮試intubate and ventilator support氣管插管及呼吸機支持cleaning (retention) enama清潔(保留)灌腸soapsuds (saline) enama肥皂

7、水(鹽水)灌腸intradermal injection皮內(nèi)注射subcutaneous (hypodermic) injection 皮下注射intramuscular injection( i.m)肌肉注射intravenous injection(i.v)靜脈注射intravenous drip(ivgtt)靜脈滴入intraarterial injection動脈注射intraarticular injection關節(jié)內(nèi)注射intrapleural injection胸腔內(nèi)注射intrathecal injection鞘內(nèi)注射intraspinal injection椎管內(nèi)注射per

8、os(P.O,by mouth口服inhalation吸入inunction涂擦scarification劃痕法by rectum直腸灌注quaque die (qd)一天1次bis in die(bid)一天2次ter in die (tid)一天3次quater in die (qid)一天4次quaque hora (qh)每小時1次quaque quarta hora(q4h)每4小時1次quaque nocte (qn)每晚1次quaque mane (qm)每晨1次ante cibum(ac)飯前(給藥)post cibum (pc)飯后(給藥)hora somni (hs)臨睡時

9、pro re nata (prn)必要時si opus sit (sos)必要時只用1次ante meridiem (am)上午post meridiem (pm)下午statim (st)即刻(2)輔助檢查術語diagnostic examinationCBC (complete blood count) 全血細胞計數(shù)WBC (white blood ount)白細胞數(shù)RBC (red blood count) 紅細胞數(shù)Ret (reticulocyte)網(wǎng)織紅細胞數(shù)HCT (hematocrit)紅細胞比積MCV (mean corpuscular volume) 紅細胞平均體積MCH (

10、mean corpuscular hemoglobin)紅細胞平均血紅蛋白EC (eosinophic count)嗜酸粒細胞計數(shù)Plt (platelet count)血小板計數(shù)UA (urine analyse)小便常規(guī)SRt (stool routine)大便常規(guī)stool OB 大便隱血stool ova count大便蟲卵計數(shù)uric acid 尿酸uric (serum) amylase 尿(血)淀粉酶urine K+ (Na+)尿鉀(鈉)測定pregnance test妊娠試驗urine Bence-Jone protein 尿本-周氏蛋白urinary protein elec

11、trophoresis尿蛋白電冰bacterial count of urine 尿菌落數(shù)osmotic pressure assay尿滲透壓測定urine (blood, stool) culture 尿(血、大便)培養(yǎng)bone marrow puncture 骨穿iron staining of bone marrow smear 骨髓鐵染色serum iron assay 血清鐵測定Vit B12 and folic acid assay 維生素B12和葉酸測定BT (bleeding time) 出血時間CT (coagulation time) 凝血時間PT (prothrombin

12、 time)凝血酶原時間ACT (activated coagulation time)活化的凝血時間KPTT(kaolin partial thromboplastin time)部分凝血活酶時間Fb (fibrinogen)纖維蛋白原FDP (fibrinogen degradation product)纖維蛋白原降解產(chǎn)物ABG (arterial blood gas)血氣分析renal function and liver function肝腎功能D-dimer fragments assayD-二聚體測定Hcy (homocysteine)同型半胱氨酸Cr and BuN (creat

13、inine and blood urea nitrogen)肌酐和尿素氮blood lipid (TG, TC ,HDL, LDL)血脂(甘油三酯,膽固醇,高密度脂蛋 白,低密度脂蛋白)myocardial enzyme (CK, CK-MB, GOT, LDH)心肌酶譜(肌酸磷酸激酶及 同功酶,谷草轉氨酶,乳酶脫氫酶)Mb (myoglobin)肌紅蛋白CTn-I 肌鈣蛋白-Ithyroid function (T3,T4,TSH,FT3 FT4,TG,TM)甲狀腺功能VMA (urine vanillylmandelic acid)尿香草基杏仁酸LH, FSH, ACTH, GH黃體生成素

14、,卵泡刺激素,促腎上腺皮質激素,生 長激素determination of calcitonin降鈣素測定17-KS and 17-OHCS尿17-酮和17-羥測定plasma cortisol assay 皮質醇aldosterone assay醛固酮testosterone and estradiol睪酮和雌二醇FBS or blood glucose 空腹血糖或血糖SaO2 monitor 血氧飽和度監(jiān)測CO2CP (carbon dioxide combining power)二氧化碳結合力Uric ketobody尿酮體serum electrolytes (K+,Na+,Ca2+,

15、Cl-,Mg2+)血電解質AFP(alpha-fetoprotein) 癌胚抗原2-M(2-microglobulin) 2微球蛋白Ccr (endogenous creatinine clearance)內(nèi)生肌酐清除率capillary resistance test 毛細血管脆性試驗platelet adhesion and aggregation test血小板粘附和凝集試驗3P test (plasma protamine paracoagulation test)血漿魚精蛋白副凝試驗plasma viscosity 血漿粘度whole-blood viscosity 全血粘度CSF

16、(cerebrospinal fluid)腦脊液semen (sputum, vaginal discharge) examination精液(痰,陰道分泌物)檢 查total protein總蛋白OGTT (oral glucose tolerance test)口服糖耐量試驗ASO (antistreptolysin O test)抗“O”試驗ANA (antinuclear antibody)抗核抗體anti-ENA antibody 抗可提取性核蛋白(ENA)抗體anti-ds DNA抗雙鏈DNA抗體C3 (complement 3) 補體3CRP (C-reactive protei

17、n) C-反應蛋白IC (immune complex)免疫復合物RF (rheumatoid factor)類風濕因子Widals reaction 肥達氏反應MIC (minimal inhibitory concentration)最低抑菌濃度MBC (minimal bactericidal concentration)最小殺菌濃度acid-fast stain抗酸染色EKG 心電圖bedside 床邊chest (cervical) X-ray examination 胸部(頸部)X線檢查P-A + lateral projection 正位+側位echo (TTE, transth

18、oracic echo)經(jīng)胸超聲心動圖echo (TEE, transesophageal echo)經(jīng)食道超聲心動圖Doppler echocardiography多普勒超聲心動圖fluoroscopy 透視醫(yī)學全在線CT (computerized-tomography)計算機斷層攝影MRI (magnetic resonance imaging)核磁共振成像DSA (digital subtractive angiography)數(shù)字減影血管造影術contrast enhancement對比增強dacryocystography淚囊造影Caldwells position 柯氏位Waye

19、rs position瓦氏位Angiography 血管造影術coronary angiography 冠脈造影術right ventricul ography 右心造影術PTCA經(jīng)皮經(jīng)腔冠脈成形術RFCA經(jīng)導管射頻消融術stent支架pacemaker implanted operation起搏器植入術Holter (dynamic ECG)24小時動態(tài)心電圖ABPM24小時動態(tài)血壓監(jiān)測treadmill test 平板運動試驗bicycle ergometer踏車試驗tilt test傾斜試驗phonocardiog raphy心音圖atropine test阿托品試驗TEAP (tran

20、sesophageal atrial pacing)食道調(diào)搏EP study電生理檢查VCG (vectocardiogram)心向量圖EMG (electromyogram)肌電圖EEG (electroencephalogram)腦電圖barium enema鋇灌腸cholangiography膽管造影術intravenous (oral) cholecystography靜脈(口服)膽囊造影pancratocholangiography胰膽管造影selective heptatic arteriography選擇性肝動脈造影bronchography支氣管造影l(fā)ung aspiration biopsy肺針吸活檢cystourethrography膀胱尿道造影IVU (intravenous urography)靜脈尿道造影retrogradepyelography逆行腎盂造影uterosalpingography子宮輸卵管造影CT-guided aspiration biopsyCT 導向下穿刺活檢cerebral

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