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入院记录翻译:中译英翻译案例

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入院记录

Hospitalization Record

主诉:左侧背部红肿痛7天

Main complaint: red and pain for 7 days at left side back

现病史:患者七天前左侧背部突然出现疼痛,无明显畏寒,发热,无恶心呕吐,未予以治疗,疼痛加剧,红肿明显,为了进一步诊断与治疗,今来我院,门诊以“背部脓肿”收入院。

Current disease history: the patient suffered pain at left back 7 days ago suddenly, without obvious aversion to cold, no nausea, and no treatment is received. But the pain gets more severe. For further diagnosis and treatment, he came to our hospital, and is hospitalized due to “apostasies at back”.

既往史:既往身体健康,否认感言,结核,高血压,糖尿病,心脏病等病史。预防接种史不详,右前额,右肘部外伤曾行清创缝合术。几年前即已发现左背部包块,较小,无疼痛,一直未予以治疗。

Medical history: healthy in the past, denied hepatitis, tuberculosis, hyopertension, diabetes, heart disease etc. No details about inoculation history. debridement and suturing operation ever received for right forehead and right elbow due to trauma. A few years ago, ever found enclosed mass at left back, which is small and no pain. So no treatment is given.

系统回顾:

System review:

头颅五官:无畏光、迎风流泪及经常流脓涕史,无嗅觉及听力障碍史,无牙痛病史。

Five sense organs of head: no photophobia, no tears when facing wind; no running nose; no hearing and listening difficulty, no toothache history.

呼吸系统:过去无咳嗽,咯痰,咳痰,呼吸苦难史。

Respiration system: no cough, expectoration, hemoptysis, aspiration difficulty history.

循环系统:过去无心悸,气急,发绀,浮肿,心前区疼痛史。

Circulating system: no palpitation, out of breath, cyanosis, edema, precordia pain history.

血液系统:无头昏、鼻血,齿龌出血及皮下瘀斑史。

Blood system: no dizziness, nosebleed, tooth or gums bleed, or ecchymoses history;

泌尿系统:无尿频、屎急、尿痛、排尿同难,无夜屎增多,无面部水肿病史。

Urinary system: no frequent and urgent urination demand, no dysuria, urination difficulty; no urination increase; no face hydropsy history;

运动系统;四肢正畸形,关节无红肿,活动自如。

Mobility system: no deformation of four limbs, no red swelling of joint. Free movement.

消化系统:无反酸、呃气、腹痛、腹泻病史。

Digestion system: no sour regurgitation, eructation, abdominal pain, diarrhea history.

内分泌系:无怕热,多汗、多饮、多食史。

Incretion system: no aversion to hot, excessive sweat; no excessive drinking or food history.

神经精神系统:无头痛、头昏史。

Nerve system: no headache or dizziness history.

个人史:生于原籍、未到过血吸虫疫区,否认道传染病疫医旅行生活史,无禽流感、SARS可疑或确诊病人接触史,平时生活规律,经济条件可,无烟洒及其他嗜好。

Personal history: born in his own country, never been to the epidemic area of schistosome; denied traveling or living history in epidemic of contagious area; no suspected or confirmed contact history of bird flu, SARS patients. Regular life, good economic conditions, no drinking, smoking or other addictions.

过敏史:否认药物及食物过敏史。

Allergic history: denied medicine or food allergic history.

婚育史:已婚,配偶身体健康,婚姻及家庭生活满意。

Marital history: married; the spouse is healthy; satisfied with marriage and family life.

家族史:家庭成员身体健康,否恶性肿瘤、心脏病、糖尿病、遗传病及传染病病史。

Family history: family members healthy; denied malignant tumour, heat disease, diabetes, hereditary disease and contagious disease history.

体格检查

Physical Examination

T 36,2℃P 72次/分R 18次/分BP110/70 mmHg

T: 36.2°C    P: 72 times/min    R: 18 times/min     BP: 110/70 mmHg

一般状况: 发育正常,营养中等,神志清楚,自动体位,步态正常,回答切题,检查合作。

General status: well developed, medium nutrition; clear minded, active position, normal walking, answering correctly, cooperation during examination.

皮肤粘膜: 垒身皮肤特膜无黄染,无紫钳、未发现皮疹及皮下出血点及瘀斑。全身皮肤未发现手术瘢痕。背部 有纹身。

Skin mucosa: no yellow stain on skin of full body, no cyanosis; no erythra, nor subcutaneous hemorrhage and petechia; operational scar not found on full body skin; tattoo on back.

淋巴结: 浅表淋巴结见肿大。

Lymph node: no swelling of lymph ndoe.

头部:头颅大小形态正常,五官端正无畸彤,眼睑无水肿,结膜无充血,眼球无突出,巩膜无黄染,取侧瞳孔等大等圆.直径约3mm,对光反射灵敏。外耳道无分泌物,乳突无压痛。无鼻扇动,鼻腔无溢液溢血,鼻旁窦无压痛。口唇红润,无发绀,口腔粘膜无出血点,舌质红.苔白薄,咽无充血,扁桃体无肿大。

Head: normal size and shape, no deformation of five organs, no hydropsy of eyelid, no hyperaemia of conjunctiva; no protrusion of eyeball; no yellow stain of sclera; equal size and round shape of pupils at both sides, with diameter about 3mm; sensitive to light. No secretion of external auditory meatus; no tenderness of mastoid; no flaring of nose. No fluid or blood from nasal cavity; no tenderness paranasal sinus; the lips are red without cyanosis; No blooding point at oral mucosa. Red tongue, white moss, no hyperaemia at throat, no tumescence of tonsil.

颈部:颈软无抵抗感,颈静脉无张,未发现异常颈动脉搏动,甲状腺不肿大.末扪及结节,气管位置居中。

Neck: bland neck without resistance; no distention of jugular vein; abnormality of abnormal pulsation of carotid not found; no swelling of thyroid; node not touched, the trachea located at center. 

胸部:胸廓对称无畸形,胸毛较多,双肺呼吸运动正常,叩诊清音,听诊呼吸音清晰,未闻及干湿性罗音。心前区无隆起,心尖搏动于左第五肋问锁骨 中线内约2cm,心浊音界正常,心率7 2次/分,心律整齐,心脏各瓣膜区未闻及病理性杂音。

Chest: chest symmetrical without deformation; a lot of sternal seta; normal aspiration of both lungs; clear sound during percussion, clear aspiration sound during acouophonia; no wet or dry rale is heard. No precordia eminence. The apex of the heart pulsates at the place about 2cm inside the central line of clavicle at left 5th rib. Normal border of cardiac dullness; HR 72 times/min with good rhythm; no pathological noise is heard at various valves of heart. 

腹部:腹部平坦,未见胃肠型及胃肠蠕动波,无腹避静脉怒张。腹式呼吸活动小受限,腹肌柔软,全腹无压痛及反跳痛,肝区无压痛,肝浊音界位置正常,肝脾未触及,Murphy氏征阴性,无移动性浊音。双肾区无压痛及叩痛,肠鸣音正常,未闻及血管杂音。

Abdomen: flat abdomen; no gastroenteric type or gastroenteric rushes; no distention of vein of abdominal wall; abdominal aspiration not limited; soft abdominal muscle; no tenderness or rebound pain at abdomen; no tenderness at liver area; normal border of liver dullness; liver and spleen not palpable. Murphy: negative. No mobile voiced sound. No tenderness or percussed pain. Normal borborygmus; no noise of blood vessels is heard.

肛门外生殖器: 未查。

Anus and external genital organs: not examined.

脊柱四肢:脊柱呈生理弯曲,无压痛及纵向叩击痛,四肢活动自如,肌力及肌张力正常。关节无肿胀,活动不受限,双下肢无浮肿、无静脉血管扩张。

Backbone and four limbs: physiological bending of backbone, no tenderness or vertical percussed pain. Free movement of four limbs. Normal muscle force and muscle strength. No swelling of joint. Movement not restricted. No swelling of both legs. No venous hemangiectasis.

神经系统:双膝反射等神经生理性反射正常,巴彬斯基氏征等病理未引出。

Nerve system: normal nervous ad psychological reflection of both knees etc. No pathological reflection of Babinski’s sign is induced.

专科检查

Specialty Examination

左侧背部见一红肿乏包块.直径大小约为5-6cm,压痛阳性,中央有波动感,局部湿度高,活动度差。

A red enclosed mass is seen at the left back, with the diameter of about 5-6cm; Positive for tenderness; fluctuation at center; high local humidity; bad movement.

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