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天风翻译西安医学翻译公司:病历中英文翻译_翻译学习 Refresher_西安翻译公司-西安天风翻译咨询有限公司-专业法律翻译公司-权威英语翻译公司
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天风翻译西安医学翻译公司:病历中英文翻译
发布时间:2010/10/21  阅读次数:9762  字体大小: 【】 【】【

天风翻译西安医学翻译公司:病历中英文翻译

住院文书格式[Admission document]
1、抗生素医嘱[Antibiotic order]
•Prophylaxis [预防性用药] Duration of order[用药时间] 24hr
Procedure[操作,手术]
•Empiric therapy [经验性治疗]
Suspected site and organism[怀疑感染的部位和致病菌] 72hr
Cultures ordered[是否做培养]
•Documented infection[明确感染]
Site and organism[部位和致病菌] 5days
•Other[其它]
Explanation required [解释理由] 24hr
•Antibiotic allergies[何种抗生素过敏]
No known allergy [无已知的过敏]
•Drug+ dose+ Route+ frequency[药名+剂量+途径+次数]
2、医嘱首页[Admission / transfer]
•Admit / transfer to [收入或转入]
•Resident [住院医师] Attending[主治医师]
•Condition [病情]
•Diagnosis[诊断]
•Diet [饮食]
•Activity [活动]
•Vital signs[测生命体征]
•I / O [记进出量]
•Allergies[过敏]
3、住院病历[case history]
•Identification [病人一般情况]
Name[性名]
Sex[性别]
Age [年龄]
Marriage[婚姻]
Person to notify and phone No.[联系人及电话]
Race[民族]
I.D. No.[身份证]
Admission date[入院日期]
Source of history[病史提供者]
Reliability of history[可靠程度]
Medical record No[病历号]
Business phone No.[工作单位电话]
Home address and phone No.[家庭住地及电话]
•Chief complaint[主诉]
•History of present illness[现病史]
•Past History[过去史]
Surgical[外科]
Medical[内科]
Medications[用药]
Allergies[过敏史]
Social History[社会史]
Habits[个人习惯]
Smoking[吸烟]
Family History[家族史]
Ob/Gyn History[ 婚姻/生育史]
Alcohol use[喝酒]
•Review of Aystems[系统回顾]
General[概况]
Eyes, Ears, Nose and throat[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]
•Physical Exam[体检]
 Vital Signs[生命体征]
P[脉博]
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]
Heart rate[心率]
Heart rhythm[心律]
Heart Border[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]
cranial nerves[颅神经]
sensation[感觉]
Motor[运动]
*Special P.E. on diseased organ system[专科情况]
*Radiographic Findings[放射]
*Laboratory Findings[化验]
*Assessment[初步诊断与诊断依据]
*Summary[病史小结]
*Treatment Plan[治疗计划]
4、输血申请单[Blood bank requisition form]
(1)reason for infusion[输血原因]
▲红细胞[packed red cells, wshed RBCs]:
*Hb<8.5 [血色素<8.5]
*>20% blood volume lost [>20%血容量丢失]
*cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素
<8]
*chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者]
▲全血[whole blood]:
massive on-going blood loss[大量出血]
▲血小板[platelets]:
*massive blood transfusion >10 units[输血10单位以上者]
*platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活
动性出血或手术者]
*Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流
术伴血小板<10万,活动性出血者]
*Platelet count <20×103/μl[血板<2万]
▲新鲜冰冻血浆[fresh frozen plasma]:
*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的
出血或手术病人]
*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏
的出血/手术者]
*blood transfusion >15units[输血>15个单位]
*warfarin or antifibrinolytic therapy with bleeding[华法令或溶栓治疗后出血]
*DIC[血管内弥漫性凝血]
*Antithrombin III dficiency[凝血酶III 缺乏]
(2)输血要求[request for blood components]
*patient blood group[血型]
*Has the patient had transfusion or pregnancy in the past 3 months? [近3个月,
病人是否输过血或怀孕过?]
*Type and crossmatch [血型和血交叉]
*Units or ml[单位或毫升]
5、出院小结[discharge summary]
 Patient Name[病人姓名]
 Medical Record No.[病历号]
 Attending Physician[主治医生]
 Date of Admission[入院日期]
 Date of Discharge[出院日期]
 Principal Diagnosis[主要诊断]
 Secondary Diagnosis[次要诊断]
 Complications[并发症]
 Operation[手术名称]
 Reason for Admission[入院理由]
 Physical Findings[阳性体征]
 Lab/X-ray Findings[化验及放射报告]
 Hospital Course[住院诊治经过]
 Condition[出院状况]
 Disposition[出院去向]
 Medications[出院用药]
 Prognosis[预后]
 Special Instruction to the Patient(diet, physical activity)[出院指导(饮食,活
 动量)]
 Follow-up Care[随随访]
6、住院/出院病历首页[Admission/discharge record]
•Patient name[病人姓名]
•race[种族]
•address[地址]
•religion[宗教]
•medical service[科别]
•admit (discharge) date[入院(出院)日期]
•Length of stay [住院天数]
•guarantor name [担保人姓名]
•next of kin or person to notify[需通知的亲属姓名]
•relation to patient[与病人关系]
•previous admit date[上次住院日期]
•admitting physician [入院医生]
•attending physician [主治医生]
•admitting diagnosis[入院诊断]
•final (principal) diagnosis[最终(主要)诊断]
•secondary diagnosis[次要诊断]
•adverse reactions (complications)[副作用(合并症)]
•incision type[切口类型]
•healing course[愈合等级]
•operative (non-operative) procedures[手术(非手术)操作]
•nosocomial infection[院内感染]
•consultants [会诊]
•Critical-No. of times[抢救次数]
•recovered-No. of times[成功次数]
•Diagnosis qualitative analysis[诊断质量]
OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率]
Clinical and pathological Dx concur[临床与病理诊断符合率]
Pre- and post-operative Dx concur [术前术后诊断符合率]
•Dx determined with in 24 hours (3 days) after admission[入院后24小时(3 天)内确诊]
•Discharge status[出院状况]
recovered[治愈]
improved[好转]
not improved[未愈]
died [死亡]
•Dispositon[去向]
home[家]
against medical ad[自动出院]
autosy[尸检]
transferred to[转院到]
  
  
general hospital综合医院
children hospital儿童医院
tumour hospital肿瘤医院
chest hospital 胸科医院
field hospital野战医院
isolation hospital隔离医院
military hospital陆军医院
municipal hospital市立医院
maternity hospital产科医院
mental hospital精神医院
infectious hospital传染医院
leprosy hospital麻风医院
affiliated hospital附属医院
training hospital教学医院
  
out-patient department门诊部
In-patient department住院部
Nursing department护理部
Admission office住院处
Discharge office 出院处
Registration office挂号处
Reception room, waiting room侯诊室
Consultation room诊察室
Isolation room隔离室
Labour room待产室
Delivery room分娩室
Emergency room急诊室
Ward病房室
Pharmacy dispensary药房
Nutrition department营养部
Diet- preparation department配膳室
Therapeutic department治疗室
Operating room手术室
Blood-bank血站
Supply-room供应室
Disinfection-room消毒室
Dressing room 换药室
Mortuary太平间
Record room病案室
  
Department of internal medicine内科
Department of surgery外科
Department of pediatrics儿科
Department of obstetrics and gynecology妇科
Department of neurology神经科
Department of ophtalmology眼科
E.N.T.department耳鼻喉科
Department of stomatology口腔科
Department of urology泌尿科
Department of orthopedic骨科
Department of traumatology创伤科
Department of endocrinology内分泌科
Department of anesthesiology麻醉科
Department of dermatology皮肤科
Department of infectious diseases传染病科
Department of pathology病理科
Department of psychiatry精神科
Department of orthopacdic surgery矫形外科
Department of cardiac surgery心脏外科
Department of cerebral surgery脑外科
Department of thoracic surgery胸外科
Department of plastic surgery矫形外科
Department of physiotherapy理疗科
electrotherapy room电疗科
heliotherapy room光疗科
wax-therapy room蜡疗科
hydrotherapy room水疗科
  
central laboratory中心实验室
clinical labororatory临床实验室
bacteriological labororatory细菌实验室
biochemical labororatory生化实验室
serological labororatory血清实验室
X-ray room X光室
doctor’s office医生办公室
nurse”s office护士办公室
  
director of the hospital院长
head of the nursing department护理部主任
attending doctor主治医师
resident doctor住院医师
intern doctor实习医师
chief physician主任医师
associate chief physician副主任医师
physician内科医师
urological surgeon泌尿外科医师
neurosurgeon 神经外科医师
plastic surgeon矫形外科医师
anestheist麻醉科耳医师
E.N.T.doctor耳鼻喉科医师
Ophthalmolgist眼科医师
Dentist牙科医师
Dermatologist皮肤科医师
Doctor for tuberculosis结核科医师
Physiotherapist理疗科
Doctor for infectious diseases传染病科
Dietician营养科医师
Pediatrist儿科医师
Obstetrician产科医师
Midwife 助产师
Gynecologist妇科医师
Orthopedist骨科医师
Radiologist放射科医师
Epidemiologist 流行病医师
Hygiemist卫生医师
Pharmacist药剂医师
Assistant pharmacist药剂医士
X-ray techmicianX光技师
Laboratory technician化验员
Head nurse护士长
Student nurse实习护士
Assistant nurse卫生员
Cleaner清洁员
Controller总务科长
Registrar 挂号员
Sanitation worker消毒员
  
First visit初诊
To attend the clinic复诊
Out-call出诊
Case history病历
Sheet-for-case history病历袋
Turnover of beds病床周转率
Average of hospital stay平均住院日数
Ward round查房
Consultation 会诊
Medical certification诊断书
Certification for leave of absence病假证明
Application for laboratory examination化验申请单
Application for X-ray examinationX光申请单
Requisition for drugs领药单
病历 case histroy
  
一般事项 date of admission /marital status /present address /correspondence / occupation
主诉 chief complaints
现病史 present illness / history of present illness
既往史 past medical history
家族史 family history
个人病史 personal history / social history
曾用药物 medications
过敏史 allergies
系统回顾 system review / review of system
体检 physical examination
一般资料 physical data 生理指标physical signs
一般状况或全身状况 general appearance
头眼与耳鼻喉 head ,eyes,ear,nose,throat ,略作heent.
胸部与心肺 CHEST,heart,and lungs
腹部 abodoms
四肢extremities
神经系统nervous system,Neurological,略作CNC或Neuro,
骨骼肌系统 Musculoskeletal
泌尿生殖系统 Genitourinary
化验室资料laboratory data/ studies /diagnosis
血液检查 blood test
化学7项指标 chem.-7
心脑电图 electrocardiogram / electroencephalogram , 略作 EKG/EEG
X线检查与x光片 X-ray examination, x-ray slides,
计算机X线断层扫描与核磁共振扫描资料 computerized x-ray tomography and nuclear magnetic resonance spectroscopy dta. CT AND NMR
其他检查资料 other lab data
印象与诊断 impression and diagnosis
住院治疗情况 hospital course
出院医嘱 discharge instructions / recommendations
出院后用药 discharge medications
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