病歷交班常見用語(Anamnesis and Shift)



病歷交班常見用語(Anamnesis and Shift)

|縮寫 |原文 |中譯 |

|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 |

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 |

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 |

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