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1、Four short words sum up what has lifted most successful individuals above the crowd: a little bit more.-author-date常用医嘱术语(英文)常用医嘱术语Medical orders常用医嘱术语Medical orders（1）医嘱术语medical ordersAdmit/transfer to收入（转入）Resident/attending住院（主诊）医师condition病情critical (Imminence)病危unstable不稳定stable稳定general (fair
2、) 一般emergent急诊Diagnosis诊断Diet饮食full (home) diet普食liquid (semi-liquid) diet流汁（半流汁）饮食soft diet软食low salt and low fat diet低盐低脂饮食salt-free diet无盐饮食low purine diet低嘌呤饮食low (non)-residue diet少（无）渣饮食light diet 清淡饮食high caloric diet高热量饮食high protein (protein-rich) diet高蛋白饮食diabetic diet糖尿病饮食nephritic diet肾炎
3、饮食nasal feeding鼻饲fasting (NPO, nothing by mouth)禁食NPO for 5 hours禁食5小时meal standard伙食标准activity活动absolute rest绝对卧床休息stay on the bed (yest in bed)卧床休息Ad lib随意活动In the ward 病房内活动vital signs生命体征Q shift (q.6h)每班（每6小时）一次immoblization制动pressed by sand bag 沙袋压迫I/O (intake and output)记出入量N/A (non-apply)不需要p
4、arameter: EKG(Bp,SaO2) monitor 其他：心电图（血压，氧饱和度）监 护allergies过敏NKA (non-known allergies)无已知的过敏反应patient identification 病人身份4th floor,room 5 ,bed 2(405-2)4楼5号房2床Med. Rec#病历号medical orders医嘱on general routine护理常规on grade I (II, III) nuring careI （I、III）级护理morning (evening) care晨间（夜间）护理bedsore care褥疮护理mou
5、th (oral) care口腔护理CPT( chest physical treatment) 胸部物理治疗O2 inhalation (2-4L/min)吸氧（2-4升/分）alcohol sponge bath酒精擦浴cold (hot) compress冷（热）敷wet (hydropathic) compress by MgSO4用硫酸镁湿敷change position qh每小时更换一次体位gastric lavage with water用清水洗胃bladder irrigation 膀胱冲洗under water seal drainage of thorax胸腔水封瓶引流G
6、I decompression 胃肠减压keep warm保温医.学 全在.线,提供lower temperature by ice-cap冰帽降温keep bowels open保持大便通畅keep the airway open保持气道通畅retention catheterization留置导尿prevent from bedsore预防褥疮on bedside isolation床边隔离P.P sitz bath高锰酸钾液坐浴raising the head (foot) of the bed抬高床头（尾）pencillin (procaine, iodine) skin test青霉
7、素（普鲁卡因，碘）皮试intubate and ventilator support气管插管及呼吸机支持cleaning (retention) enama清洁（保留）灌肠soapsuds (saline) enama肥皂水（盐水）灌肠intradermal injection皮内注射subcutaneous (hypodermic) injection 皮下注射intramuscular injection( i.m)肌肉注射intravenous injection(i.v)静脉注射intravenous drip(ivgtt)静脉滴入intraarterial injection动脉注射
8、intraarticular injection关节内注射intrapleural injection胸腔内注射intrathecal injection鞘内注射intraspinal injection椎管内注射per os(P.O,by mouth口服inhalation吸入inunction涂擦scarification划痕法by rectum直肠灌注quaque die (qd)一天1次bis in die(bid)一天2次ter in die (tid)一天3次quater in die (qid)一天4次quaque hora (qh)每小时1次quaque quarta hora
9、(q4h)每4小时1次quaque nocte (qn)每晚1次quaque mane (qm)每晨1次ante cibum(ac)饭前（给药）post cibum (pc)饭后（给药）hora somni (hs)临睡时pro re nata (prn)必要时si opus sit (sos)必要时只用1次ante meridiem (am)上午post meridiem (pm)下午statim (st)即刻(2)辅助检查术语diagnostic examinationCBC (complete blood count) 全血细胞计数WBC (white blood ount)白细胞数RB
10、C (red blood count) 红细胞数Ret (reticulocyte)网织红细胞数HCT (hematocrit)红细胞比积MCV (mean corpuscular volume) 红细胞平均体积MCH (mean corpuscular hemoglobin)红细胞平均血红蛋白EC (eosinophic count)嗜酸粒细胞计数Plt (platelet count)血小板计数UA (urine analyse)小便常规SRt (stool routine)大便常规stool OB 大便隐血stool ova count大便虫卵计数uric acid 尿酸uric (se
11、rum) amylase 尿（血）淀粉酶urine K+ (Na+)尿钾（钠）测定pregnance test妊娠试验urine Bence-Jone protein 尿本-周氏蛋白urinary protein electrophoresis尿蛋白电冰bacterial count of urine 尿菌落数osmotic pressure assay尿渗透压测定urine (blood, stool) culture 尿（血、大便）培养bone marrow puncture 骨穿iron staining of bone marrow smear 骨髓铁染色serum iron assa
12、y 血清铁测定Vit B12 and folic acid assay 维生素B12和叶酸测定BT (bleeding time) 出血时间CT (coagulation time) 凝血时间PT (prothrombin time)凝血酶原时间ACT (activated coagulation time)活化的凝血时间KPTT(kaolin partial thromboplastin time)部分凝血活酶时间Fb (fibrinogen)纤维蛋白原FDP (fibrinogen degradation product)纤维蛋白原降解产物ABG (arterial blood gas)血
13、气分析renal function and liver function肝肾功能D-dimer fragments assayD-二聚体测定Hcy (homocysteine)同型半胱氨酸Cr and BuN (creatinine and blood urea nitrogen)肌酐和尿素氮blood lipid (TG, TC ,HDL, LDL)血脂（甘油三酯，胆固醇，高密度脂蛋 白，低密度脂蛋白）myocardial enzyme (CK, CK-MB, GOT, LDH)心肌酶谱（肌酸磷酸激酶及 同功酶，谷草转氨酶，乳酶脱氢酶）Mb (myoglobin)肌红蛋白CTn-I 肌钙蛋白
14、-Ithyroid function (T3,T4,TSH,FT3 FT4,TG,TM)甲状腺功能VMA (urine vanillylmandelic acid)尿香草基杏仁酸LH, FSH, ACTH, GH黄体生成素，卵泡刺激素，促肾上腺皮质激素，生 长激素determination of calcitonin降钙素测定17-KS and 17-OHCS尿17-酮和17-羟测定plasma cortisol assay 皮质醇aldosterone assay醛固酮testosterone and estradiol睾酮和雌二醇FBS or blood glucose 空腹血糖或血糖Sa
15、O2 monitor 血氧饱和度监测CO2CP (carbon dioxide combining power)二氧化碳结合力Uric ketobody尿酮体serum electrolytes (K+,Na+,Ca2+,Cl-,Mg2+)血电解质AFP(alpha-fetoprotein) 癌胚抗原2-M(2-microglobulin) 2微球蛋白Ccr (endogenous creatinine clearance)内生肌酐清除率capillary resistance test 毛细血管脆性试验platelet adhesion and aggregation test血小板粘附和凝
16、集试验3P test (plasma protamine paracoagulation test)血浆鱼精蛋白副凝试验plasma viscosity 血浆粘度whole-blood viscosity 全血粘度CSF (cerebrospinal fluid)脑脊液semen (sputum, vaginal discharge) examination精液（痰，阴道分泌物）检 查total protein总蛋白OGTT (oral glucose tolerance test)口服糖耐量试验ASO (antistreptolysin O test)抗“O”试验ANA (antinucle
17、ar antibody)抗核抗体anti-ENA antibody 抗可提取性核蛋白（ENA）抗体anti-ds DNA抗双链DNA抗体C3 (complement 3) 补体3CRP (C-reactive protein) C-反应蛋白IC (immune complex)免疫复合物RF (rheumatoid factor)类风湿因子Widals reaction 肥达氏反应MIC (minimal inhibitory concentration)最低抑菌浓度MBC (minimal bactericidal concentration)最小杀菌浓度acid-fast stain抗酸染
18、色EKG 心电图bedside 床边chest (cervical) X-ray examination 胸部（颈部）X线检查P-A + lateral projection 正位+侧位echo (TTE, transthoracic echo)经胸超声心动图echo (TEE, transesophageal echo)经食道超声心动图Doppler echocardiography多普勒超声心动图fluoroscopy 透视医学全在线CT (computerized-tomography)计算机断层摄影MRI (magnetic resonance imaging)核磁共振成像DSA (d
19、igital subtractive angiography)数字减影血管造影术contrast enhancement对比增强dacryocystography泪囊造影Caldwells position 柯氏位Wayers position瓦氏位Angiography 血管造影术coronary angiography 冠脉造影术right ventricul ography 右心造影术PTCA经皮经腔冠脉成形术RFCA经导管射频消融术stent支架pacemaker implanted operation起搏器植入术Holter (dynamic ECG)24小时动态心电图ABPM24小
20、时动态血压监测treadmill test 平板运动试验bicycle ergometer踏车试验tilt test倾斜试验phonocardiog raphy心音图atropine test阿托品试验TEAP (transesophageal atrial pacing)食道调搏EP study电生理检查VCG (vectocardiogram)心向量图EMG (electromyogram)肌电图EEG (electroencephalogram)脑电图barium enema钡灌肠cholangiography胆管造影术intravenous (oral) cholecystograph
21、y静脉（口服）胆囊造影pancratocholangiography胰胆管造影selective heptatic arteriography选择性肝动脉造影bronchography支气管造影lung aspiration biopsy肺针吸活检cystourethrography膀胱尿道造影IVU (intravenous urography)静脉尿道造影retrogradepyelography逆行肾盂造影uterosalpingography子宫输卵管造影CT-guided aspiration biopsyCT 导向下穿刺活检cerebral angiography 脑血管造影ver
22、tebral angiography椎动脉造影cisternography脑室造影arterio (veno) graphy动（静）脉造影lung functional examination肺功能检查gastroscopy胃镜检查endoscopy內窥镜检查sigmoidoscopy乙状结肠镜查colonoscopy结肠镜检查colonofiberscopy纤维结肠镜检查bronchoscopy支气管镜检查ERCP (endoscopic retrograde cholangio-pancreatography)经内镜逆行胰胆管造影catheterization导尿术医学全在线thorace
23、ntesis胸穿abdominocentesis（abdominal puncture）腹穿pericardiocentesis心包穿刺liver (renal) biopsy肝（肾）活检bone marrow puncture骨穿lumbar puncture腰穿lymah node puncture 淋巴结穿刺joint cavity paracentesis 关节腔穿刺术examination of prostate前列腺检查massage of prostate前列腺按摩CVP measure 中心静脉压测定peripheral venous pressure measure 外周静脉压测定duodenal drainage十二指肠引流该文章转载自医学全在线：-