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专业病历翻译的几个关键步骤(中英文对照)

专业的病历翻译件构成
 
我们选择的这一系列英文病历一般包括Chief complaint(主诉)、Past medical history(过往病史)、Examination(医院检查)、Clinical course(临床过程)和Case follow-up(复查情况)几个部分。

Chief Complaint
 
R. F., a 42-year-old woman, has been complaining of atypical headaches for the past few weeks. She experienced vomiting with one of the headaches that she could not attribute to the flu or something she had eaten. She does not have a history of migraines. R. F. had an appointment with a neurologist, who referred her to the neurosurgery clinic for evaluation of a possible cerebral hemorrhage.
 
 
主诉
 
R. F.,女,42岁。诉过去几周有非典型性头痛,其中一次伴随呕吐,与流感及进食无关。无偏头痛史。神经科医生检查后,将其转至神经外科诊室,确诊是否有脑出血。
 
Examination
 
Patient is a 42-YO female c/o sudden and severe headaches over the past three to four weeks; one headache was accompanied with vomiting. Patient admits to recent photophobia and intermittent blurred vision. She has a history of venous thrombi following an emergency hip surgery for a fracture she suffered two years ago when she was in an automobile accident. Multiple vertebrae and her pelvis were also fractured. No other complications postaccident noted. Hypertensive with a BP of 154/86; neurological and physical examination is otherwise normal. Diagnoses: cerebral aneurysm and hypertension.
 
 
医院检查
 
病人为42岁女性,诉过去3-4周内突发急剧头痛;其中一次伴有呕吐。诉近期有畏光及间歇性视力模糊。两年前车祸导致骨折,行髋部急诊手术,其后有静脉血栓。多节椎骨及骨盆亦发生骨折,事故后无其他并发症记录。高血压154/86mmHg;神经系统检查及查体无其他异常。诊断结果:脑动脉瘤,高血压。
 
 
Clinical course
 
The neurologist ordered a CT scan that revealed a small saccular aneurysm measuring 4 mm near the circle of Willis, the arterial pathway supplying the brain. R. F. was scheduled for a craniotomy and surgical insertion of a clip around the neck of the aneurysm to control bleeding and offer protection from rebleeding.
 
临床过程
 
神经科医生安排了CT检查,结果示近Willis环(大脑动脉环)有4mm囊状小动脉瘤。R. F.接受了开颅手术,并于动脉瘤瘤体颈部置入动脉瘤夹以控制出血,并预防再次出血。
 
 
Case follow-up
 
R. F. underwent a craniotomy in which a special clip was placed around the neck of the aneurysm. She was closely observed for postoperative neurolocial deficits, including vascular spasm, a serious possible complication. She tolerated the procedure well with no complications.
 
复查情况
 
R. F. 接受了开颅手术,并于动脉瘤颈置入了专用夹。术后接受了神经功能损伤方面的严密观察,包括可能出现的严重神经痉挛。术后观察结果正常,未见并发症。

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