2018年7月17日 翻译与写作

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无论是原文还是译文，病历记录的纲要式结构大致一样：

一般项目（general data） 主诉（chief complaint） 现病史（present history） 既往史（past history） 家族史（family history） 体格检查（physical examination） 实验检查和其他辅助检查（laboratory and aided examination） 诊断（diagnosis）

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] Cultures ordered[是否做培养]

Documented infection[明确感染] Site and organism[部位和致病菌] Other[其它]

Explanation required [解释理由] 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]l P[脉博] Bp[血压] R[呼吸] T[温度]

Height[身高] Weight[体重] General[概况]l HEENT[五官] Neck[颈部]

Back/Chest[背部/胸部] Breast[乳房] Heart[心脏]l Heart rate[心率] Heart rhythm[心律] Heart Border[心界]

Murmur[杂音] Abdomen[腹部]l Liver[肝] Spleen[脾] Rectal[直肠] Genitalia[生殖系统]

Extremities[四肢]l 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]: *Hb20%血容量丢失] *cardio-pulmonary bypass with anticipated Hb [心肺分流术伴预计血色素 ] *chemotherapy or surgery with Hb