病历的语言特点及翻译祥解.ppt

查体:患者,男,发育良好,营养状况佳,情绪低落,并不特别痛苦。血压128/75,脉博90,正常有力。体温正常。身高:180cm。颈软,无肿物。呼吸正常,无哮喘或干湿罗音,呼吸音清。 心血管系统正常,窦性心律,无杂音。 人体右心房上有一个特殊的小结节，由特殊的细胞构成，叫做窦房结。它可以自动地、有节律地产生电流，电流按传导组织的顺序传送到心脏的各个部位，从而引起心肌细胞的收缩和舒张。人体正常的心跳就是从这里发出的，这就是“心脏起搏点”。窦房结每发生1次冲动，心脏就跳动1次，在医学上称为“窦性心律”。所以，心脏正常的跳动就应该是窦性心律。 (2)病人系因“车祸外伤术后近3天伴气促、呼吸困难”入院。查体:发育正常,营养中等,昏迷状,双侧瞳孔针尖样大小,直径约1·5mm,光反射消失,经口气管插管,留置经鼻胃管。颈软,双侧胸腔闭式引流,引流瓶可见气泡不断溢出。右侧胸腔引流管留置在右腋中线4、5肋间位置,左侧留置在左锁骨中线第二肋间,引流管不断有新鲜血性液体流出,双上肺呼吸音清晰,可闻少许湿音,心脏 (-),腹肌紧张,右肝下引流管2根,左肝下引流管2根,膀胱直肠凹引流管2根,均见血性液体流出。 The patient was admitted for hospitalization for “3 days after surgery for injuries in car accident， coupled with short breath and difficult respiration”· Review of systems: This was a well-developed, moderately-nourished male patient in a coma, with both pupils as small as needle point and of a diameter of about1·5m.Light reflex disappeared· Tracheal tube through mouth and gastric tube through nose· Neck was supple· Closed drainage from both chest cavities.Bubbles effused continuously from drainage bottle.The right drainage tube was set between the 4th and 5th rib on the midaxillary line, while the left one at the 2nd rib on the left medioclavicular line, with fresh bloody fluid effused continuously from bilateral drainage tubes Both lungs had clear respiration sound in the upper parts, with some moist rales. Heart (-)· Abdominal muscle was in a tension state, with 2 drainage tubes from the right hepatic region, 2 drainage tubes from the left hepatic region and 2 drainage tubes from the rectovesical pouch.No bloody fluid from these tubes 手术记录的段落篇章,英文和中文相似,基本上只有一段,按手术的先后逻辑顺序,用句法结构完整的句子和过去时态,一气呵成。 病理报告单的段落篇章,英文与中文也相似,如果一个标本有几个病理检查结果,每个病理结果单独成段。如: 超声描述 　　—————— 二尖瓣口血流: E/A1。 　　　二尖瓣口收缩期见反流信号+。 　　　三尖瓣口收缩期见反流信号++。 Description of the ultrasonic image: 　　—————— Blood velocity at the bicuspid valve: E/A1 　　Bicuspid regurgitation is positive (+) during contraction phase· 　　Tricuspid regurgitation is positive (++) during contraction phase· 人有了知识，就会具备各种分析能力， 明辨是