不論是護理師日常交班,或是藥師在用藥評估時,有良好的英文病歷閱讀和撰寫能力是非常重要的。
有時候可能因為錯誤的理解或是病歷撰寫不完整造成醫療照護上的缺口,甚至是造成疏失,
因此,掌握最基本常見的醫療單字和縮寫是入門的第一步,以下整理了部分常見用語:
病歷交班常見用語(Anamnesis and Shift)
縮寫 |
英文 |
中文 |
Abd |
Abdomen |
腹部 |
Adm |
Admission |
入院 |
B.S. |
Breathing sounds |
呼吸音 |
D.N.R. |
Do Not Resuscitation |
放棄心肺復甦術 |
E.N.T. |
ear ,nose, throat |
耳鼻喉 |
F/U |
Follow up |
追蹤治療 |
G.M.R. |
General medical routine |
一般內科常規 |
G.S.R. |
General surgical routine |
一般外科常規 |
Hx. |
History |
病史 |
F.H. |
Family history |
家族病史 |
P.H. |
Past history |
過去病史 |
Imp. |
Impression |
臆斷(初步診斷) |
I&O,I/O |
Intake output |
輸出輸入 |
Rx. |
Medication (recipe) |
處方 |
Nil. |
None |
無 |
P’t |
Patient |
病人 |
P.E. |
Physical examination |
身體檢查 |
S/P |
Post-surgical |
手術後 |
P.I. |
Present illness |
現在病況 |
R/0 |
Rule out |
可能是,疑似 |
Tx. |
Treatment/Therapy |
治療 |
|
Chill |
寒顫 |
|
Coma |
昏迷 |
|
Complication |
合併症 |
|
Consciousness confused |
意識混亂 |
|
Constipation |
便秘 |
|
Convulsion |
痙攣 |
|
Cough |
咳嗽 |
|
Cyanosis |
發紺 |
|
Diarrhea |
腹瀉 |
|
Dislocation |
脫位,脫臼 |
|
Dizziness |
眩暈 |
|
Drug resistance |
抗藥性 |
|
Pitting edema |
凹陷性水腫 |
|
Headache |
頭痛 |
|
hematuria |
血尿 |
|
Infection |
感染 |
|
Injury |
損傷 |
|
Nausea |
噁心 |
|
Occult blood |
潛血 |
|
Abdominal pain |
腹痛 |
|
Bloody stool |
血便 |
|
Tarry stool |
黑便 |
|
Stylet |
通條 |
|
Suction catheter /tube |
抽痰管 |
延伸閱讀 :
病房常見檢查之全名
縮寫 |
英文 |
中文 |
BMD |
Bone densitometry |
骨質密度 |
ESWL |
Extracorporeal shock wave lithotripsy |
體外震動波碎石術 |
ERCP |
Endoscopic retrograde cholangiopancreatography |
內視鏡逆行性膽道胰臟攝影術 |
IVP |
Intravenous pyelography |
靜脈注射腎盂攝影術 |
MRI |
Magnetic resonance imaging |
磁振造影 |
PTCD |
Percutaneous transhepatic drainage |
經皮穿肝膽道引流術 |
PTA |
Percutaneous transluminal angioplasty |
經皮血管內血管形成術 |
TAE |
Transarterial embolization |
經動脈式栓塞治療 |
TEE |
Transesophageal echocardiography |
經食道是心臟超音波檢查 |
UD |
urodynamic |
尿動力學 |
心血管系統常見診斷
縮寫 |
英文 |
中文 |
ABE |
Acute bacterial endocarditis |
急性細菌性心內膜炎 |
Af |
Atrial fibrillation |
心房纖維顫動 |
AF |
Atrial flutter |
心防震顫 |
AMI |
Acute myocardial infarction |
急性心肌梗塞 |
APC |
Atrial premature contraction |
心室房早期縮收 |
ASD |
Atrial septal defect |
心房中膈缺損 |
AR |
Aortic regurgitation |
主動脈瓣回流 |
AS |
Aortic stenosis |
主動脈瓣狹窄 |
AVB |
Atrioventricular block |
心房心室傳導阻斷 |
AVR |
Aortic valve replacement |
主動脈瓣替換 |
BVH |
Biventricular hypertrophy |
兩側心臟肥大 |
CAD |
Coronary artery disease |
冠狀動脈疾病 |
CHF |
Congestive cardio failure |
充血性心臟衰竭 |
CHD |
Congenital heart disease |
先天性心臟疾病 |
CRBBB |
Complete right bundle-branch block |
心房室 |
DVT |
Deep venous thrombosis |
深部靜脈栓塞 |
DCMP |
Dilated cardiomyopathy |
擴張性心肌病變 |
HCM |
Hypertrophic cardiovascular disease |
肥厚性心肌病變 |
HCVD |
Hypertensive cardiovascular disease |
高血性心血管疾病 |
IRBBB |
Incomplete right bundle branch block |
右心房室束支不完全性傳導阻斷 |
IHD |
Ischemic heart disease |
缺血性心臟病 |
MR |
Mitral regurgitation (reflux) |
僧帽瓣回流 |
MS |
Mitral stenosis |
僧帽瓣狹窄 |
MVR |
Mitral valve replacement |
僧帽瓣替換 |
PAF |
Paroxysmal atrial fibrillation |
陣發性心房纖維顫動 |
PSVT |
Paroxysmal ventricular tachycardia |
陣發性心室心搏過速 |
PTCA |
Percutanous transluminal coronary angioplasty |
經皮冠狀血管形成形術 |
RHD |
Rheumatic heart disease |
風濕性心臟病 |
TVR |
Tricuspid valve replacement |
三尖瓣置換 |
TI |
Tricuspid insufficiency |
三間瓣不全 |
VT |
Ventricular tachycardia |
心室搏過速動 |
VPC |
Ventricular premature contraction |
心室早期收縮 |
VSD |
Ventricular septal defect |
心室中膈缺損 |
腎臟及泌尿系統常見診斷
縮寫 |
英文 |
中文 |
AGN |
Acute glomerulonephritis |
急性腎絲球腎炎 |
APN |
Acute pyelonephritis |
急性腎盂腎炎 |
ARF |
Acute renal failure |
急性腎衰竭 |
BPH |
Benign prostatic hypertrophy |
良性前列性肥大 |
CGN |
Chronic glomerulonephritis |
慢性腎絲球腎炎 |
CPN |
Chronic pyelonephritis |
慢性腎盂腎炎 |
CRD |
Chronic renal disease |
慢性腎病 |
CRF |
Chronic renal failure |
慢性腎衰竭 |
CRI |
Chronic renal insufficiency |
慢性腎功能不全 |
|
Dysuria |
排尿困難 |
ESRD |
End stage renal disease |
末期腎臟病 |
|
Gout |
痛風 |
HD |
Hemodialysis |
血液透析 |
|
Hematuria |
血尿 |
PD |
Peritoneal dialysis |
腹膜透析 |
|
Neurogenic bladder dysfunction |
神經性膀胱功能失調 |
|
Nephritic syndrome |
腎病症候群 |
|
Polycystic kidney disease |
腹膜透析 |
SIADH |
Syndrome of inappropriate antidiuretic |
抗利尿性激素不適當症候群 |
TURP |
Transurethral resection of the prostate |
經尿道前列腺切除 |
|
Uremia |
尿毒症 |
UTI |
Urinary tract infection |
尿道感染 |
呼吸系統常見診斷
縮寫 |
英文 |
中文 |
ARSD |
Acute respiratory distress syndrome |
急性呼吸困難症候群 |
|
Acute respiratory failure |
急性呼吸衰竭 |
|
Adenocarcinoma |
腺癌 |
|
Asthmatic bronchitis |
氣喘性支氣管炎 |
|
Bronchial asthma |
支氣管性氣喘 |
COPD |
Chronic obstructive pulmonary disease |
慢性阻塞性肺疾病 |
|
Dyspnea |
呼吸困難 |
|
Emphysema |
肺氣腫 |
|
Empyema |
膿胸 |
|
Hemothorax |
血胸 |
|
Lung cancer |
肺癌 |
|
Lung abscess |
肺膿瘍 |
|
Mycoplasmal pneumonia |
黴漿菌肺炎 |
|
Orthopnea |
端坐呼吸 |
|
Pulmonary edema |
肺水腫 |
|
Pulmonary embolism |
肺栓塞 |
|
Pulmonary infarction |
肺梗塞 |
|
Pleural effusion |
肋膜積水 |
|
Pneumonia |
肺炎 |
|
Pneumothorax |
氣胸 |
TB |
Pulmonary tuberculosis |
肺結核 |
|
Respiratory distress |
呼吸窘迫 |
SOB |
Short of breath |
呼吸短促 |
URI |
Upper respiratory tract infection |
上呼道感染 |
消化系統常見診斷
縮寫 |
英文 |
中文 |
ADV |
Acute duodenal ulcer |
急性十二指腸潰瘍 |
AGE |
Acute gastroenteritis |
急性腸胃炎 |
|
Alcoholic liver disease |
酒精性肝炎 |
|
Anorexia |
厭食症 |
|
Ascites |
腹水 |
|
Appendicitis |
闌尾炎 |
CBD stone |
Common bile duct stone |
總膽管結石 |
|
Colon cancer |
結腸癌 |
|
Colostomy |
結腸造口術 |
|
Chronic hepatitis |
慢性肝炎 |
|
Cholecystitis |
膽囊炎 |
|
Dysphagia |
吞嚥困難 |
|
Edema |
水腫 |
|
Esophageal cancer |
食道癌 |
EV |
Esophageal varices |
食道靜脈曲張 |
|
Epigastralia |
上腹痛 |
|
Fecal impaction |
糞便填塞 |
|
Gastric ulcer |
胃潰瘍 |
|
Gastric cancer |
胃癌 |
HCC |
Hepatocellular carcinoma |
肝細胞癌 |
HE |
Hepatic encephalopathy |
肝性腦病變 |
|
Hemorrhagic erosive gastritis |
出血性糜爛性胃炎 |
|
Hemorrhoid |
痔瘡 |
|
Hematemesis |
吐血 |
|
Hepatitis |
肝炎 |
|
Hepatoma |
肝癌 |
|
Hernia |
疝氣 |
|
Hypoalbuminemia |
低蛋白血症 |
|
Intestinal obstructive |
腸閉塞 |
|
Indigestion |
消化不良 |
|
Ileus |
腸阻塞 |
|
Jaundice |
黃疸 |
|
Jejunostomy |
空腸造口術 |
|
Liver cirrhosis |
肝硬化 |
|
Liver abscess |
肝膿瘍 |
|
Liver parenchyma |
肝實質及病 |
|
Massive ascites |
大量腹水 |
PUD |
Peptic ulcer disease |
消化性潰瘍 |
PPU |
Perforation of peptic ulcer |
穿孔性消化性潰瘍 |
|
Peritonitis |
腹膜炎 |
|
Portal hypertension |
門脈高壓 |
|
pancreatitis |
胰臟炎 |
|
Splenomegaly |
脾腫大 |
|
Ulcerative colitis |
潰瘍性結腸炎 |
延伸閱讀 :