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.l Date of Admission入院日期l Date of Discharge出院日期 l Pirncipal Diagnosis主要診斷l(xiāng) Secondary Diagnosis次要診斷 l Complications并發(fā)癥l Operation手術名稱 l Reason for Admission入院理由l Physical Findings陽性體征 l Lab/X-ray Findings化驗及放射報告l Hospital Course住院診治經過 l Condition出院狀況l Disposition出院去向 l Medications出院用藥l Prognosis預后l Special Instruction to the Patient(diet, physical activity)出院指導(飲食,活l 動量)l Follow-up Care隨隨訪6、住院/出院病歷首頁Admission/discharge recordPatient name病人姓名 race種族address地址 religion宗教medical service科別admit (discharge) date入院(出院)日期Length of stay 住院天數guarantor name 擔保人姓名next of kin or person to notify需通知的親屬姓名relation to patient與病人關系previous admit date上次住院日期admitting physician 入院醫(yī)生attending phgsician主治醫(yī)生admitting diagnosis入院診斷final (principal) diagnosis最終(主要)診斷secondary diagnosis次要診斷adverse reactions (complications)副作用(合并癥)incision type切口類型healing course愈合等級operative (non-operative) procedures手術(非手術)操作nosocomial infection院內感染consutants會診Critical-No. of times搶救次數recovered-No. of times成功次數Diagnosis qualitative analysis診斷質量 OP.adm.and discharge Dx concur 門診入院與出院診斷符合率 Clinical and pathological Dx concur臨床與病理診斷符合率 Pre- and post-operative Dx concur 術前術后診斷符合率Dx determined with in 24 hours (3 days) after admission入院后24小時(3 天)內確診Discharge status出院狀況 recovered治愈 improved好轉 not improved未愈 died 死亡Dispositon去向 home家 against medical ad自動出院 autosy尸檢 transferred to轉院到第十八章 附錄Appendix附1 常用解剖術語anatomic terms1、總論Introductionsuperior上inferior下Cranial頭側Caudal尾側anterior前posterior后ventral腹側dorsal背側medial內側lateral外側internal內external外superficial淺profundal深proximal近側distal遠側ulnar尺側radial橈側tibial脛側fibular腓側2、運動系統(tǒng)locomotor (kinetic) systemvertebrae椎骨cervical vevtebrae頸椎thoracic vertebrae胸椎lumbar vertebrae腰椎sacrum骶骨sternum胸骨rib肋骨thoracic cage胸廓skull顱frontal bone額骨parietal bone頂骨occipital bone枕骨temporal bone顳骨sphenoid bone蝶骨ethmoid bone篩骨mandible (submaxilla)下頜骨maxilla (supermaxilla)上頜骨nasal bone鼻骨coronal (sagital, lambdoid) suture 冠狀(矢狀,人字)縫orbit眶clavicle鎖骨scapula (shoulder blade)肩胛骨sternum (breast bone)胸骨manubrium sterni (presternum)胸骨柄midsternum胸骨體xiphoid劍突humerus肱骨radius橈骨ulna尺骨carpal bone腕骨metacarpal bone 掌骨phalanges指(趾)骨hip bone髖骨ilium髂骨ischium 坐骨pubis恥骨femur 股骨patella髕骨tibia脛骨fibula 腓骨articulation關節(jié)ligament韌帶flexion屈extension伸adduction收abduction展medial rotation旋內lateral rotation旋外pronation旋前supination旋后circumductoin環(huán)轉vertebral column脊柱intervertebral disc椎間盤temporal-mandibular joint顳下頜關節(jié)shoulder joint肩關節(jié)elbow joint肘關節(jié)radiocarpal joint肩關節(jié)radiocarpal joint橈腕關節(jié)pelvis骨盆hip joint髖關節(jié)knee joint膝關節(jié)ankle joint踝關節(jié)muscle 肌肉tendon肌腱fascia筋膜tendinous sheath腱鞘trapezius斜方肌latissimus dorsi背闊肌sternocleidomastoid胸鎖乳突的scalenus 斜角肌pectoralis major胸大肌intercostales肋間肌diaphragm膈肌inguinal canal腹股溝管masseter咬肌temporalis顳肌deltoid三角肌biceps brachii肱二頭肌triceps brachii肱三頭肌axillary fossa 腑窩gluteus maximus臀大肌piriformis梨狀肌sartorius縫匠肌quadriceps femoris股四頭肌triceps surae小腿三頭肌femoral triangle股三角3、內臟Visceraviscera內臟oral cavity口腔lip唇cheek頰palate腭tooth牙dentes牙tongue舌parotid gland腮腺pharynx咽esophagus食管stomach gaster胃duodenum十二指腸jejunum空腸ileum 回腸large intestine大腸caecum盲腸vermiform (appendix)闌尾colon結腸rectum直腸anal canal肛管dentate line齒狀線anus肛門liver (hepar)肝porta hepatis肝門gallblader膽囊pancreas胰nose鼻nasal cavity鼻腔paranasal sinus鼻旁竇larynx喉laryngeal cavity喉腔vocal cord聲帶trachea氣管bronchi支氣管lung 肺pulmonary肺的pleura胸膜mediastinum縱隔kidney腎renal pilvis腎盂ureter輸尿管urinary bladder膀胱urethra尿道testis睪丸epididymis附睪ductus deferens輸精管spermatic cord精索prostate前列腺scrotum陰囊penis陰莖ovary卵巢uterine tube輸卵管uterus子宮vagina陰道clitoris陰蒂mamma (breast)乳房mammary papilla (nipple)乳頭perineum會陰pelvic diaphragm盆膈peritoneum腹膜omentum網膜4、心血管系統(tǒng)Cardiovascular systemheart心artery動脈vein靜脈capillary毛細血管atrium心房ventricle心室tricuspid valve三尖瓣bicuspid valve二尖瓣aortic valve主動脈瓣pulmonary valve肺動脈瓣sinuatrial node竇房結atrioventricular node房室結atrioventricular bundle房室束right/left bundle branch右/左束支coronary artery冠狀動脈coronary sinus冠狀竇pericardium心包aorta主動脈innominate artery無名動脈(頭臂干)common carotid artery頸總動脈carotid sinus 頸動脈竇internal(external) carotid artery頸內(外)動脈facial artery面動脈subclavian artery鎖骨下動脈mesenteric artery腸系膜動脈common iliac artery髂總動脈popliteal artery 腘動脈vena cava 腔靜脈internal jugular vein頸內靜脈cephalic vein頭靜脈basilic vein貴要靜脈saphenous vein隱靜脈lymphatic duct淋巴導管thoracic duct胸導管lymph node淋巴結spleen脾thymus胸腺5、感覺器sense organssensory organ感覺器receptor感受器visual organ視器eyeball 眼球cornea角膜sclera鞏膜choroid 脈絡膜ciliary body睫狀體iris虹膜retina視網膜optic disc視神經盤macula lutea黃斑aqueous humor房水lens晶狀體vitreous body玻璃體eyelid 眼瞼conjunctiva結膜lacrimal gland淚腺vestibulocochlear organ前庭蝸器ear( auris) 耳auricle耳廓acoustic meatus耳道tympanic cavity鼓室tympanic membrane鼓膜pharyngotympanic tube 咽鼓管bony(membranous) labyrinth骨(膜)迷路vestibule 前庭semicircular canal半規(guī)管cochlea耳蝸cochlear duct蝸管olfactory organ嗅器gustatory organ味器taste bud味蕾skin皮膚6、神經系統(tǒng)Nervous systemcentral nervous system中樞神經系統(tǒng)peripheral nervous system周圍神經系統(tǒng)visceral nerve內臟神經afferent nerve傳入神經efferent nerve傳出神經neuron神經元axon 軸突dendrite樹突glia 神經膠質gray matter 灰質white matter白質cortex皮質madulla髓質nucleus神經質ganglion神經節(jié)fasciculus神經束nerve神經spinal nerve脊神經cervical plexus頸叢brachial plexus臂叢lumbar plexus腰叢sacral plexus 骶叢phrenic nerve膈神經median nerve正中神經ulnar nerve尺神經radial nerve橈神經femoral nerve股神經ischiatic nerve坐骨神經common peroneal nerve腓總神經cranial nerve顱(腦)神經olfactory nerve嗅神經optic nerve視神經oculomotor nerve動眼神經trochlear nerve滑車神經trigeminal verve三叉神經abducent nerve展神經facial nerve面神經vestibulocochlear nerve前庭蝸神經glossopharyngeal nerve舌咽神經vagus nerve迷走神經accessary nerve副神經hypoglossal nerve舌下神經autonomic nervous system自主神經vegetative nervous system植物神經sympathetic nerve交感神經parasympathetic nerve副交感神經spinal cord脊髓encephalon (brain)腦brain stem腦干medulla oblongata延髓pons 腦橋mesencephalon中腦midbrain中腦cerebellum小腦diencephalon間腦thalamus丘腦hypothalamus下丘腦hypophysis垂體telencephalon端腦cerebrum大腦cerebral cortex大腦皮質corpus striatum紋狀體internal capsule內囊spinothalamic tract皮質脊髓束medial lemniscus內側丘系lateral lemniscus外側丘系spinal lemniscus脊髓丘系trigeminal lemniscus三叉丘系7、體表標記Anatomic marksnaso-labial groove鼻唇溝suprasternal fossa胸骨上窩supraclavicular fossa鎖骨上窩infraclavicular fossa鎖骨下窩armpit (axillary fossa)腋窩midsternal (midian) line胸骨中線(正中線)anterior midian line前正中線parasternal line胸骨旁線midclavicular line鎖骨中線mammillary (nipple, milk) line乳線posterior (mid-, anterior) axillary line腋后(中,前)線scapular line肩胛線midspinal line脊柱中線dorsomedian line后正中線linea paravertebralis 脊椎旁線the left (right) upper abdomen (quadrant)左(右)上腹epigastrium上腹部the middle abdomen中腹部the lower abdomen下腹部linea pararectalis腹直肌旁線anterior superior spine髂前上棘symphysis pubis (symphysion)恥骨聯合ischial tuberosity坐骨結節(jié)groin (inguen)腹股溝popliteal fossa腘窩upper extremity(limb)上肢lower extremity(limb)下肢posterior superior spine髂后上嵴anterior (dorsal) part of chest(前(后)胸部)scapular region肩胛區(qū)anterior (posterior) fontanelle前(后)囪附2 醫(yī)學英語常用前后綴a-無,缺 anemia貧血 atonia無張力 asymptomatic無癥狀的 amenorrhea閉經ab-分離 abduct 外展 abscision切除acou (acu)-聽覺 acumeter 聽力計 acouophone助聽器acro-肢端 acromegaly肢端肥大癥 acromastitis乳頭炎ad (af, an)-鄰近,向上 adrenal 腎上腺 adaxial近軸的 annexa附件-ad側 ventrad向腹側 cephalad向頭側adeno-腺 adenocyte腺細胞 adenoidism腺體病adipo-脂肪 adiposis肥胖癥 adiponecrosis脂肪壞死adreno-腎上腺 adrenocorticoid腎上腺皮質激素 adrenalin腎上腺素 adrenal腎上腺-aemia(emia)血癥 bacteremia菌血癥 leukemia白血病-albi (albino)-白色 albumin白蛋白 albinism白化病-algesia痛覺 hypoalgesia痛覺減退-algia痛 arthralgia關節(jié)痛cephalgia頭痛neuralgia神經痛alkali-堿alkalosis堿中毒alveo-牙槽,小溝 alveolitis牙槽炎 alveobronchiolitis支氣管肺泡炎ambi-復,雙 ambiopia復視 ambivert雙重性格ambly-弱amblyopia弱視 amblyaphia觸覺遲鈍amylo-淀粉amyloidosis淀粉酶 amylase淀粉酶angio-血管 angiography血管造影術 angioedema血管性水腫 angeitis脈管炎 angiofibroma血管纖維瘤ante-前antenatal出生前的 anteflexion前屈antero-前anterolateral前側壁 anteroventral前腹側anti-抗,反antibiotics抗生素 antihypertensives降壓藥 anticoagulant抗凝劑rarchno-蛛網膜arachnoiditis蛛網膜炎archo-肛門,直腸archorrhagia肛門出血 archosyrinx直腸灌注器arterio-動脈arteriospasm動脈痙攣 arteriosclerosis動脈硬化arthro-關節(jié)arthrocentesis關節(jié)穿刺 arthrotomy關節(jié)切開術 arthritis關節(jié)炎-ase酶oxidase氧化酶 proteinase蛋白酶-asthenia無力myasthenia肌無力 neurasthenia神經衰弱audio(audito)-聽力audiology聽覺學 audiometer聽力計auto-自己autoimmune自身免疫auto hemotherapy自體血療法bacilli-桿菌bacillosis桿菌病 bacilluria桿菌尿bacterio-細菌bacteriology細菌學 bactericide殺菌劑baro-壓力barometer 壓力計 baroreceptor壓力感受器bary-遲鈍barylalia言語不清 baryacusia聽覺遲鈍bi-雙 bicuspid二尖瓣 bilateral兩側的bili-膽汁bilirubin膽紅素bio-生命biology生物學 biopsy活檢-blast母細胞spermatoblast精子細胞 melanoblast成黑色素細胞 osteoblast成骨細胞brachy-短brachypnea氣短brachydactylia短指畸形brady-遲緩bradycardia心動過緩 bradypsychia精神不振broncho-支氣管bronchoscopy支氣管鏡檢查 bronchiostenosis支氣管痙攣bronchitis支氣管炎bronchiolo-細支氣管bronchiolectasis細支氣管擴張calci-鈣calcification鈣化 calcicosilicosis鈣沉著癥carbo-碳carbohydrate碳水化合物 carbohaemia碳酸血癥carcino-癌carcinogen致癌物cardio-心,賁門cardiotonics強心劑cardioplasty賁門成形術-cele疝,腫物omphalocele臍疝 hysterocele子宮脫垂 ophthalmocele眼球突出celio-腹celialgia腹痛 celioscopy腹腔鏡檢查-centesis穿刺arthrocentesis關節(jié)穿刺術abdominocentesis腹穿cephalo-頭cephaloxia斜頸cephalopathy頭部疾病cephalotomy穿顱術cerebello-小腦cerebellitis小腦炎cerebellum小腦cerebro-大腦cerebritis大腦炎cerebrology腦學chemo-化學chemotherapy化療chloro-綠,氯chloroform氯仿 chloromycetin氯霉素chlorophyll葉綠素cholangio-膽道cholangitis膽管炎 cholangiectasis膽管擴張cholo-膽cholagogue利膽劑 cholelithiasis膽石癥cholecystitis膽囊炎cholesterol膽固醇chondro-軟骨chondrosarcoma軟骨肉瘤 chondrification骨軟化chromo-色素cytochrome細胞色素chromosome染色體-cide殺劑germicide殺菌劑aborticide墮胎藥circum-周圍circumoral口周的circumcision包皮環(huán)切術coagulo-凝固coagulant凝血劑colo-結腸colotomy結腸切開術coloptosis結腸下垂colpo (coleo)-陰道coleospastia陰道痙攣colposcope陰道鏡contra-反,逆contraindication禁忌證contraceptive避孕藥counter-反,逆counteragent拮抗劑conuterpoison解毒劑cranio-顱craniomalacia顱骨軟化cranioclasis碎顱術-cyst-囊cystomy膀胱切開術dacryocyst淚囊-cyte-細胞lymphocyte淋巴細胞cytolysis細胞溶解de-除去detoxication解毒dento牙dentistry牙科學dentalgia牙痛-derm-皮膚epiderm表皮dermatology皮膚病學dermoplasty皮膚成形術dextro-右dextrocardia右位心dexiotropic右旋的dis-分離discission分離術disinfection消毒法duodeno-十二指腸duodenitis十二指腸炎duodenostomy十二指腸造口術-dynia痛acrodynia肢體痛urethrodynia尿道痛dys-異常dysfunction功能不良dyshormonism內分泌障礙dysuria排尿困難-ectasis擴張gastroectasis胃擴張aerenterectasia腸脹氣bronchiectasia支氣管擴張-ectomy切除術appendectomy闌尾切除術lipectomy脂肪切除術-edema水腫encephaledema腦水腫myxedema粘液性水腫-emesia嘔hematemesia嘔血helminthemesia吐蟲encephalo-腦encephaloma腦瘤encephaledema腦水腫endo-內endocarditis心內膜炎endoscope內窺鏡entero-腸enteritis腸炎enterovirus腸病毒epi-上,外epigastrium上腹部erythro-紅erythromycin紅霉素erythroderma紅皮病esophago-食管esophagoscope食管鏡esophagitis食管炎extra-外extracellular細胞外的extrasystole額外收縮facio-面facioplegia面癱facioplasty面部成形術-fast耐acid-fast抗酸的uviofast耐紫外線febri-熱febricula低熱febrifacient致熱的feti-胎兒feticulture妊娠期衛(wèi)生fetometry胎兒測量法fibro-纖維fibroblast成纖維細胞fibrosis纖維化fore-前forebrain前腦forehead前額-form形狀oviform卵形的granuliform顆粒狀的fungi-真菌,霉菌fungicide殺真菌劑fungistasis制霉菌作用gastro-胃gastroptosis胃下垂gastroenteritis胃腸炎gastroscopy胃鏡檢查gastratrophy胃萎縮-gen 原,劑glycogen糖原pathogen病原體androgen雄激素Estrogen雌激素-genic性cardiogenic心源性的allergenic變應反應giganto-巨大 gigantocyte巨紅細胞gigantism巨大癥gingivo-牙齦gingivitis牙齦炎gingivostomatitis牙齦口腔炎glosso-舌glossoplegia舌癱瘓gluco-糖glucoprotein糖蛋白glucocorticoid糖皮質激素glyco-糖glycogen糖原glycouria糖尿-grade級,度centigrade攝氏溫度計retrograde逆行性-gram克,圖microgram微克electroencephalogram腦電圖-graph(y)儀(法) electrocardiogram心電圖bronchography支氣管造影術gyneco-婦女gynecology婦科學gynecopathy婦科病hemo(hemato)-血hemoglobin血紅蛋白hematoma血腫hemi-半hemiplegia偏癱hemicrania偏頭病hepato-肝hepatitis肝炎hepatocirrhosis肝硬化hepatosplenomegaly肝脾腫大hidro-汗hyperhidrosis多汗癥anhidrosis無汗癥histo-組織histology組織學histomorphology組織形態(tài)學holo-全holonarcosis全麻holoenzyme全酶homo-同homotype同型homologue同系物homoplasty同種移植術hydro-水hydropericardium心包積水hydrolysis 水解hypr-高 hypercalcemia高鈣血癥hyperthyroidism甲亢hypno-睡眼hypnotics安眠藥hypnotherapy催眠療法hypo-低hypotension低血壓hypoglycemia低血糖hystero-子宮hysterospasm子宮痙攣hysteroptosis子宮下垂-ia病melancholia憂郁癥pyrexia發(fā)熱-iatrics醫(yī)學pediatrics兒科學geriatrics老年病學-iatry醫(yī)學psychiatry精神病學pediatry兒科學immuno-免疫immunoglobulin免疫球蛋白immunotherapy免疫療法infra-下infraorbital眶下的infrared紅外線inter-間intervertebral椎間的intercellular細胞間的intra-內intravenous靜脈內的intracranial顱內的intramuscular肌肉內的-ist家pathologist病理學家anatomist解剖學家-itis炎癥cellulitis蜂窩織炎myocarditis心肌炎leuco 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