1)對(duì)藥物性狀的說(shuō)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.

　　它是一種白色至微黃色粉末，加適量水可配制成近乎白色的懸濁液，供肌肉注射用，或配制成黃色的溶液，供靜脈注射用。

　　2)在藥物作用方面

　　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.

　　它是一種抗菌素，不但能抵抗大多數(shù) B內(nèi)酰銨酶，而且抵抗各種革蘭氏陽(yáng)性和革蘭氏陰性細(xì)菌。

　　3)適應(yīng)癥

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

　　在感染的細(xì)菌未被確認(rèn)出來(lái)，或由敏感細(xì)菌引起感染時(shí)，適于用它來(lái)治療。

　　4)用量用法方面

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

　　許多感染可用肌肉注射或靜脈注射 750毫升，每日三次即可見(jiàn)效。

　　5)禁忌癥

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

　　對(duì)該藥物過(guò)敏者禁止使用。

　　6)不良反應(yīng)

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

　　該藥耐受性良好，最常見(jiàn)的副作用與胃腸道癥狀有關(guān)。

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

　　偶爾可能出現(xiàn)下列副作用：口干、口渴、發(fā)困、乏力、頭暈、心部燒灼感、食欲不振、腹部不適、藥疹。

　　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.

　　偶爾可能對(duì)口腔粘膜有麻醉作用，但若不嚼碎藥片，而以水送服，上述作用可以避免。

　　8)貯存

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

　　密封避光，置于干燥陰涼處保存。

　　9)劑型

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

　　安瓿，內(nèi)裝 10mg……，凍干粉

      1、抗生素醫(yī)囑[Antibiotic order]

　　Prophylaxis [預(yù)防性用藥]

　　Duration of order[用藥時(shí)間] 24hr

　　Procedure[操作，手術(shù)]

　　Empiric therapy [經(jīng)驗(yàn)性治療]

　　Suspected site and organism[懷疑感染的部位和致病菌]

　　Cultures ordered[是否做培養(yǎng)]

　　Documented infection[明確感染]

　　Site and organism[部位和致病菌]

　　Other[其它]

　　Explanation required [解釋理由]

　　Antibiotic allergies[何種抗生素過(guò)敏]

　　No known allergy [無(wú)已知的過(guò)敏]

　　Drug+ dose+ Route+ frequency[藥名+劑量+途徑+次數(shù)]

　　2、醫(yī)囑首頁(yè)[Admission / transfer]

　　Admit / transfer to [收入或轉(zhuǎn)入]

　　Resident [住院醫(yī)師] Attending[主治醫(yī)師]

　　Condition [病情]

　　Diagnosis[診斷]

　　Diet [飲食]

　　Activity [活動(dòng)]

　　Vital signs[測(cè)生命體征]

　　I / O [記進(jìn)出量]

　　Allergies[過(guò)敏]

　　3、住院病歷[case history]

　　Identification [病人一般情況]

　　Name[性名]

　　Sex[性別]

　　Age [年齡]

　　Marriage[婚姻]

　　Person to notify and phone No.[聯(lián)系人及電話]

　　Race[民族]

　　I.D. No.[身份證]

　　Admission date[入院日期]

　　Source of history[病史提供者]

　　Reliability of history[可靠程度]

　　Medical record No[病歷號(hào)]

　　Business phone No.[工作單位電話]

　　Home address and phone No.[家庭住地及電話]

　　Chief complaint[主訴]

　　History of present illness[現(xiàn)病史]

　　Past History[過(guò)去史]

　　Surgical[外科]

　　Medical[內(nèi)科]

　　Medications[用藥]

　　Allergies[過(guò)敏史]

　　Social History[社會(huì)史]

　　Habits[個(gè)人習(xí)慣]

　　Smoking[吸煙]

　　Family History[家族史]

　　Ob/Gyn History[ 婚姻/生育史]

　　Alcohol use[喝酒]

　　Review of Aystems[系統(tǒng)回顧]

　　General[概況]

　　Eyes, Ears, Nose and throat[五官]

　　Pulmonary[呼吸]

　　Cardiovascular[心血管]

　　GI[消化]

　　GU[生殖、泌尿系統(tǒng)]

　　Musculoskeletal[肌肉骨骼]

　　Neurology[神經(jīng)系統(tǒng)]

　　Endocrinology[內(nèi)分泌系統(tǒng)]

　　Lymphatic/Hematologic[淋巴系統(tǒng)/血液系統(tǒng)]

　　Physical Exam[體檢]

　　Vital Signs[生命體征]l

　　P[脈博]

　　Bp[血壓]

　　R[呼吸]

　　T[溫度]

　　Height[身高]

　　Weight[體重]

　　General[概況]l

　　HEENT[五官]

　　Neck[頸部]

　　Back/Chest[背部/胸部]

　　Breast[乳房]

　　Heart[心臟]l

　　Heart rate[心率]

　　Heart rhythm[心律]

　　Heart Border[心界]

　　Murmur[雜音]

　　Abdomen[腹部]l

　　Liver[肝]

　　Spleen[脾]

　　Rectal[直腸]

　　Genitalia[生殖系統(tǒng)]

　　Extremities[四肢]l

　　Neurology[神經(jīng)系統(tǒng)]

　　cranial nerves[顱神經(jīng)]

　　sensation[感覺(jué)]

　　Motor[運(yùn)動(dòng)]

　　Special P.E. on diseased organ system[專(zhuān)科情況]

　　Radiographic Findings[放射]

　　Laboratory Findings[化驗(yàn)]

　　Assessment[初步診斷與診斷依據(jù)]

　　Summary[病史小結(jié)]

　　Treatment Plan[治療計(jì)劃]

　　4、輸血申請(qǐng)單[Blood bank requisition form]

　　(1)reason for infusion[輸血原因]

　　▲紅細(xì)胞[packed red cells, wshed RBCs]:

　　*Hb<8.5 [血色素<8.5]

　　*>20% blood volume lost [>20%血容量丟失]

　　*cardio-pulmonary bypass with anticipated Hb [心肺分流術(shù)伴預(yù)計(jì)血色素 ]

　　*chemotherapy or surgery with Hb <10[血色素<10的化療或手術(shù)者]

　　▲全血[whole blood]:

　　massive on-going blood loss[大量出血]

　　▲血小板[platelets]:

　　*massive blood transfusion >10 units[輸血10單位以上者]

　　*platelet count <50×103/μl with active bleeding or surgery[血小板<5萬(wàn)伴活動(dòng)性出血或手術(shù)者]

　　*Cardio-pulmonary bypass uith pl<100×103/μlwith octive bleeding[心肺分流術(shù)伴血小板<10萬(wàn)，活動(dòng)性出血者]

　　*Platelet count <20×103/μl[血板<2萬(wàn)]

　　▲新鮮冰凍血漿[fresh frozen plasma]:

　　*documented abnormal PT or PTT with bleeding orSurgery[PT、PTT異常的出血或手術(shù)病人]

　　*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手術(shù)者]

　　*blood transfusion >15units[輸血>15個(gè)單位]

　　*warfarin or antifibrinolytic therapy withbleeding[華法令或溶栓治療后出血]

　　*DIC[血管內(nèi)彌漫性凝血]

　　*Antithrombin III dficiency[凝血酶III 缺乏]

　　(2)輸血要求[request for blood components]

　　*patient blood group[血型]

　　*Has the patient had transfusion or pregnancy in the past 3 months? [近3個(gè)月，病人是否輸過(guò)血或懷孕過(guò)?]

　　*Type and crossmatch [血型和血交叉]

　　*Units or ml[單位或毫升]

　　5、出院小結(jié)[discharge summary]

　　Patient Name[病人姓名]l

　　Medical Record No.[病歷號(hào)]l

　　Attending Physician[主治醫(yī)生]l

　　Date of Admission[入院日期]l

　　Date of Discharge[出院日期]l

　　Principal Diagnosis[主要診斷]l

　　Secondary Diagnosis[次要診斷]l

　　Complications[并發(fā)癥]l

　　Operation[手術(shù)名稱(chēng)]l

　　Reason for Admission[入院理由]l

　　Physical Findings[陽(yáng)性體征]l

　　Lab/X-ray Findings[化驗(yàn)及放射報(bào)告]l

　　Hospital Course[住院診治經(jīng)過(guò)]l

　　Condition[出院狀況]l

　　Disposition[出院去向]l

　　Medications[出院用藥]l

　　Prognosis[預(yù)后]l

　　Special Instruction to the Patient(diet,physical activity)[出院指導(dǎo)(飲食，活動(dòng)量)]l

　　Follow-up Care[隨隨訪]l

　　6、住院/出院病歷首頁(yè)[Admission/discharge record]

　　Patient 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(shù)]

　　guarantor name [擔(dān)保人姓名]

　　next of kin or person to notify[需通知的親屬姓名]

　　relation to the patient[與病人關(guān)系]

　　previous admit date[上次住院日期]

　　admitting physician [入院醫(yī)生]

　　attending physician [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(lèi)型]

　　healing course[愈合等級(jí)]

　　operative (non-operative) procedures[手術(shù)(非手術(shù))操作]

　　nosocomial infection[院內(nèi)感染]

　　consultants [會(huì)診]

　　Critical-No. of times[搶救次數(shù)]

　　recovered-No. of times[成功次數(shù)]

　　Diagnosis qualitative analysis[診斷質(zhì)量]

　　OP.adm.and discharge Dx concur [門(mén)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(shù)前術(shù)后診斷符合率]

　　Dx determined with in 24 hours (3 days) afteradmission[入院后24小時(shí)(3 天)內(nèi)確診]

　　Discharge status[出院狀況]

　　recovered[治愈]

　　improved[好轉(zhuǎn)]

　　not improved[未愈]

　　died [死亡]

　　Dispositon[去向]

　　home[家]

　　against medical ad[自動(dòng)出院]

　　autosy[尸檢]

　　transferred to[轉(zhuǎn)院到]