外科查房常用英语

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1、最全的医学英语之NO.11、抗生素医嘱[Antibioticorder]Prophylaxis预防性用药Durationofoder用药时间Procedure操作，手术Empirictheraphy经验性治疗Suspectedsiteandorganism怀疑感染的部位和致病菌Culturesordered做培养Documentedinfection明确感染Siteandorganism部位和致病菌Explanationrequired解释理由Antibioticallergies何种抗生素过敏Noknownallergy无已知的过

2、敏Drug+dose+Route+frequency药名+剂量+途径+次数2、医嘱首页[Admission/transfer]Admit/transferto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Vitalsigns生命体征I/O记进出量Allergies过敏3、住院病历[casehistory]Identification病人一般情况Name姓名Sex性别Age年龄Marriage婚姻PersontonotifyandphoneNo

3、.联系人及电话Race民族I.D.No.身份证Admissiondate入院日期Sourceofhistory病史提供者Reliabilityofhistory可靠程度MedicalrecordNo病历号BusinessphoneNo工作单位电话HomeaddressandphoneNo家庭住地及电话Chiefcomplaint主诉Historyofpresentillness现病史PastHistory过去史Surgical外科Medical内科Medications用药Allergies过敏史SocialHistory社会史Ha

4、bits个人习惯Smoking吸烟FamilyHistory家族史Ob/GynHistory婚姻/生育史Alcoholuse喝酒ReviewofSystems系统回顾General概况Eyes,Ears,Noseandthroat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PhysicalExam体检VitalSigns生命体征P脉博

5、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Heartrate心率Heartrhythm心律HeartBorder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cranialnerves颅神经sensation感觉Motor运动*SpecialP.E.ondiseasedorgansystem[专科情况]*Rad

6、iographicFindings[放射]*LaboratoryFindings[化验]*Assessment[初步诊断与诊断依据]*Summary[病史小结]*TreatmentPlan[治疗计划]4、输血申请单[Bloodbankrequisitionform](1)reasonforinfusion[输血原因]▲红细胞[packedredcells,washedRBCs]:*Hb<8.5[血色素<8.5]*>20%bloodvolumelost[>20%血容量丢失]*cardio-pulmonarybypasswithanti

7、cipatedHb<8[心肺分流术伴预计血色素<8]*chemotherapyorsurgerywithHb<10[血色素<10的化疗或手术者]▲全血[wholeblood]:massiveon-goingbloodloss[大量出血]▲血小板[platelets]:*massivebloodtransfusion>10units[输血10单位以上者]*plateletcount<50×103/μlwithactivebleedingorsurgery[血小板<5万伴活动性出血或手术者]*Cardio-pulmonarybypass

8、uithpl<100×103/μlwithoctivebleeding[心肺分流术伴血小板<10万，活动性出血者]*Plateletcount<20×103/μl[血板<2万]▲新鲜冰冻血浆[freshfrozenplasma]:*d