常用临床医学术语.doc

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1、.lDateofAdmission[入院日期]lDateofDischarge[出院日期]lPirncipalDiagnosis[主要诊断]lSecondaryDiagnosis[次要诊断]lComplications[并发症]lOperation[手术名称]lReasonforAdmission[入院理由]lPhysicalFindings[阳性体征]lLab/X-rayFindings[化验及放射报告]lHospitalCourse[住院诊治经过]lCondition[出院状况]lDisposition[出院去向]lMedications[出院用药]l

2、Prognosis[预后]lSpecialInstructiontothePatient(diet,physicalactivity)[出院指导（饮食，活l动量）]lFollow-upCare[随随访]6、住院/出院病历首页[Admission/dischargerecord]·Patientname[病人]·race[种族]·address[地址]·religion[]·medicalservice[科别]·admit(discharge)date[入院（出院）日期]·Lengthofstay[住院天数]·guarantorname[担保人]·nexto

3、fkinorpersontonotify[需通知的亲属]·relationtopatient[与病人关系]·previousadmitdate[上次住院日期]·admittingphysician[入院医生]·attendingphgsician[主治医生]·admittingdiagnosis[入院诊断]·final(principal)diagnosis[最终（主要）诊断]·secondarydiagnosis[次要诊断]·adversereactions(complications)[副作用（合并症）]·incisiontype[切口类型]·heal

4、ingcourse[愈合等级]·operative(non-operative)procedures[手术（非手术）操作]·nosocomialinfection[院感染]·consutants[会诊]·Critical-No.oftimes[抢救次数]·recovered-No.oftimes[成功次数]·Diagnosisqualitativeanalysis[诊断质量]OP.adm.anddischargeDxconcur[门诊入院与出院诊断符合率]ClinicalandpathologicalDxconcur[临床与病理诊断符合率]Pre-andp

5、ost-operativeDxconcur[术前术后诊断符合率]·Dxdeterminedwithin24hours(3days)afteradmission[入院后24小时（3天）确诊]·Dischargestatus[出院状况]recovered[治愈]improved[好转]notimproved[未愈]died[死亡]·Dispositon[去向]home[家]againstmedicalad[自动出院]autosy[尸检]transferredto[转院到]第十八章附录[Appendix]附1常用解剖术语[anatomicterms]1、总论[I

6、ntroduction]·superior[上]·inferior[下]·Cranial[头侧]·Caudal[尾侧]·anterior[前]·posterior[后]·ventral[腹侧]·dorsal[背侧]·medial[侧]·lateral[外侧]·internal[]·external[外]·superficial[浅]·profundal[深]·proximal[近侧]·distal[远侧]·ulnar[尺侧]·radial[桡侧]·tibial[胫侧]·fibular[腓侧]2、运动系统[locomotor(kinetic)system]·

7、vertebrae[椎骨]·cervicalvevtebrae[颈椎]·thoracicvertebrae[胸椎]·lumbarvertebrae[腰椎]·sacrum[骶骨]·sternum[胸骨]·rib[肋骨]·thoraciccage[胸廓]·skull[颅]·frontalbone[额骨]·parietalbone[顶骨]·occipitalbone[枕骨]·temporalbone[颞骨]·sphenoidbone[蝶骨]·ethmoidbone[筛骨]·mandible(submaxilla)[下颌骨]·maxilla(supermaxill

8、a)[上颌骨]·nasalbone[鼻骨]·coronal(sag