医学翻译中病例翻译的常见术语（医学病例翻译专业词汇）

　　1)对药物性状的说明

　　It is a white or a faintly yellow powder to which appropriate amounts of water are added to prepare an off white suspension for intramuscular use or a yellowish solution for intravenous administration.

　　它是一种白色至微黄色粉末，加适量水可配制成近乎白色的悬浊液，供肌肉注射用，或配制成黄色的溶液，供静脉注射用。

　　2)在药物作用方面

　　It is a bactericidal antibiotic which is resistant to most B-lastamases and is active against a wide range of Gram-positive and Gram-negative organism.

　　它是一种抗菌素，不但能抵抗大多数 B内酰铵酶，而且抵抗各种革兰氏阳性和革兰氏阴性细菌。

　　3)适应症

　　It is indicated for the treatment of infection before the infecting organism has been identified or When caused by sensitive bacteria.

　　在感染的细菌未被确认出来，或由敏感细菌引起感染时，适于用它来治疗。

　　4)用量用法方面

　　Many infections will respond to 750mgt d s by i.m. or by i v.

　　许多感染可用肌肉注射或静脉注射 750毫升，每日三次即可见效。

　　5)禁忌症

　　It should not be used in patients with known sensitivity to the drug

　　对该药物过敏者禁止使用。

　　6)不良反应

　　This drug is generally well tolerated. The commonest side effects associated with it are symptoms related to the gastrointestinal tract.

　　该药耐受性良好，最常见的副作用与胃肠道症状有关。

　　The following adverse reactions may occasionally occur：dryness of the mouth，thirst，drowsiness，fatigue，dizziness，heartburn，anorexia，abdominal discomfort and exanthema.

　　偶尔可能出现下列副作用：口干、口渴、发困、乏力、头晕、心部烧灼感、食欲不振、腹部不适、药疹。

　　7)注意

　　An anesthetic effect on the oral mucous membranes may occur occasionally，but may be avoided by swallowing the drug quickly with water without crashing the tablet.

　　偶尔可能对口腔粘膜有麻醉作用，但若不嚼碎药片，而以水送服，上述作用可以避免。

　　8)贮存

　　Keep airtight in a dry and cool place. Away from light.

　　密封避光，置于干燥阴凉处保存。

　　9)剂型

　　(How supplied)10 mg vial containing 10 mg of …as a freeze powder 10 mg.

　　安瓿，内装 10mg……，冻干粉

      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]:

　　*Hb<8.5 [血色素<8.5]

　　*>20% blood volume lost [>20%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 <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/μlwith 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 orSurgery[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 withbleeding[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]l

　　Medical Record No.[病历号]l

　　Attending Physician[主治医生]l

　　Date of Admission[入院日期]l

　　Date of Discharge[出院日期]l

　　Principal Diagnosis[主要诊断]l

　　Secondary Diagnosis[次要诊断]l

　　Complications[并发症]l

　　Operation[手术名称]l

　　Reason for Admission[入院理由]l

　　Physical Findings[阳性体征]l

　　Lab/X-ray Findings[化验及放射报告]l

　　Hospital Course[住院诊治经过]l

　　Condition[出院状况]l

　　Disposition[出院去向]l

　　Medications[出院用药]l

　　Prognosis[预后]l

　　Special Instruction to the Patient(diet,physical activity)[出院指导(饮食，活动量)]l

　　Follow-up Care[随随访]l

　　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 the 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) afteradmission[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]