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白岩松耶鲁大学演讲稿（幽默风趣）：现场交替口译 附演讲稿中英对照
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中英文对照病历，用词绝对地道，留学生亲手翻译
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住院病历的英汉对照(此病历为我校留学生所写，用词绝对地道）中文部分Adimissionfor record科别 呼吸内科
姓名：×××
职业：退休性别：男
住址或电话：年龄：82岁
病史陈述者：患者婚否：已婚
联系人及电话： 籍贯：
入院时间：民族：汉
记录日期：主诉：反复咳嗽、咳痰、伴气喘30年，加重一天现病史：患者近30年来于冬春季节获气候变换时反复出现咳嗽、咳痰，多为白色粘液痰，伴活动后气喘，症状逐渐加重，曾于我科住院治疗，诊断为慢性支气管炎、肺气肿，予以抗感染、化痰、平喘及对症支持等处理后症状有所改善，但每于受凉后反复发作，平时反复有咳嗽、咳白色粘液痰症状，昨日患者受凉后出现病情加重，伴气喘明显，前来我院就诊，摄胸片示慢性支气管炎、肺气肿改变，故为进一步诊治再入住我科，病情中患者有发热，无盗汗、咯血，无胸痛、心悸，无头痛、头昏，无嗳气、返酸，无恶心、呕吐，无腹痛、腹胀，无双下肢浮肿，精神食纳差，大小便如常。既往史：既往有“冠心病”史，否认“高血压、糖尿病”病史，否认“肝炎、血吸虫、结核”等病史。无手术及外伤史。有青霉素过敏史。系统回顾头颈五官无视力障碍，耳聋、耳鸣、眩晕、鼻出血、牙痛、牙龈出血及声音嘶哑史循环系统无心悸、活动后气促、心前区痛、下肢水肿、腹水、头晕、头痛、晕厥，无高血压及风湿病史消化系统无嗳气、反酸、吞咽困难、腹痛、腹泻、呕吐、黄疸、呕血和黑便史。泌尿系统无尿频、尿急、尿痛、腰痛、血尿、尿量异常、排尿困难、血压升高、颜面水肿史造血系统无皮肤苍白、头晕、眼花、耳鸣、记忆力减退、心悸、舌痛、皮肤粘膜出血、黄疸、淋巴结及肝脾肿大、骨骼痛史内分泌与代谢系统无怕热、多汗、乏力、头痛、视力障碍、烦渴、多尿、水肿、显著肥胖或明显消瘦史。无毛发增多或脱落、色素沉着、性功能改变。肌肉骨骼系统 无疼痛、关节红肿、关节畸形、肢体活动障碍及肌无力、肌肉萎缩神经系统 无头痛、晕厥、记忆力减退、语言障碍、失眠、意识障碍、皮肤感觉异常、瘫痪、抽搐精神状态无幻觉、妄想、定向力障碍、情绪异常史。个人史出生并长期生活于原籍，无“日本血吸虫病、疟疾”疫水接触史，无烟酒与特殊嗜好，无“粉尘、毒物”接触史婚育史 适龄结婚，配偶体检
5-6家族史家族中无遗传性疾病及传染病史
体格检查T ： 37.4oC
P：95次/分
R：21次/分
BP: 160/75mmHg一般情况
发育正常，营养良好，体型正常，神志清楚，精神差，营养中等，发育正常，自动体位，查体合作。皮肤黏膜
全身皮肤黏膜无黄染、红斑、皮疹和色素沉着。淋巴结全身浅淋巴结肿大未扪及。头部及其器官
头型正常，头发色黑，有光泽，分布均匀，头部无疤痕
眼：眼睑无水肿，结膜未见出血点，巩膜无黄染，角膜透明，双侧瞳孔等大等圆，直径3mm,对光反射灵敏
耳：无流脓及乳突压痛，听力正常
鼻：鼻道通畅，中隔无偏曲，无流涕，上颌窦与额窦无压痛
口：唇红，无发绀，牙齿排列整齐，牙龈无红肿流脓，扁桃体正常无红肿，声音无嘶哑颈部 无抵抗，两侧对称，无颈静脉怒张，并可见颈动脉搏动，气管居中，甲状腺不再肿大胸部胸廓对称，胸式呼吸为主，呼吸节律正常
视：呼吸运动两侧相等，桶状胸。 触：两侧呼吸动度均等，两侧语言震颤减低，无胸膜摩擦感。 叩：呈过清音，肺下界位于右侧锁骨中线上第5肋间，肩胛线第9肋间，左侧肩胛线第10肋间，双肺下界移动度约4cm。听：两肺呼吸音低，闻及散在干性啰音。心脏：视：心前区无隆起，心尖搏动于左侧第5肋间锁骨中线内1.0cm。搏动范围直径约1.5cm触：心尖部无震颤、摩擦感及抬举性搏动，心尖搏动位置同上叩：心脏相对浊音界如下：
右侧（cm）
左侧（cm）
8锁骨中线与前正中线之间距离为9厘米听：心率95次/分，心律整齐，第一心音正常，各瓣膜听诊区未及病理性杂音桡动脉：搏动有力，节律整齐，无奇脉或脉搏短绌、水冲脉，血管壁弹性正常，脉率120次/分。周围血管征：无毛细血管搏动及枪击音腹部
视：腹对称，腹壁静脉无曲张，无肠型及胃肠蠕动波触：腹软，无压痛、反跳痛，肝、脾和肾未触及。叩：无移动性浊音，下腹部呈浊音听：肠鸣音1分钟内未闻及肛门与直肠：无肛裂、脱肛、瘘管和痔疮，直肠指检正常，未发现肿物，无狭窄和压痛。外生殖器：未查脊柱及四肢：脊柱正常，四肢无畸形，无红肿，关节活动不受限，肌张力无异常。神经系统：四肢肌力检查不配合，肌张力对称。腱反射存在，双下肢巴氏征未引出。专科检查：神志清楚，精神差，口唇无紫绀，气管居中，桶状胸，两侧触觉语颤减低，叩诊呈过清音，两肺呼吸音低，闻及散在干性啰音。
实验室及器械检查全胸片（ 本院 检查号）：慢性支气管炎伴肺气肿改变心电图（本院）：窦性心动偏速，电轴左偏，完全性右束支传导阻滞，提示左心室肥大，P-R间期延长。血常规（本院）：WBC9.4*109/l，N79.9%
病史摘要患者×××，男，82岁，因“反复咳嗽、咳痰、伴气喘30年，加重一天”入院，既往有“冠心病”史，有青霉素过敏史。患者近30年来于冬春季节获气候变换时反复出现咳嗽、咳痰，多为白色粘液痰，伴活动后气喘，症状逐渐加重，曾于我科住院治疗，诊断为慢性支气管炎、肺气肿，予以抗感染、化痰、平喘及对症支持等处理后症状有所改善，但每于受凉后反复发作，平时反复有咳嗽、咳白色粘液痰症状，昨日患者受凉后出现病情加重，伴气喘明显，前来我院就诊，摄胸片示慢性支气管炎、肺气肿改变，故为进一步诊治再入住我科，病情中患者有发热，无盗汗、咯血，无胸痛、心悸，无头痛、头昏，无嗳气、返酸，无恶心、呕吐，无腹痛、腹胀，无双下肢浮肿，精神食纳差，大小便如常。入院时查体：T ： 37.4oC,P：95次/分,R： 21次/分,BP: 160/75mmHg神志清楚，精神差，口唇无紫绀，气管居中，桶状胸，两侧触觉语颤减低，叩诊呈过清音，两肺呼吸音低，闻及散在干性啰音。心率95次/分，律齐，未闻及病理性杂音。全胸片（ 本院 检查号）：慢性支气管炎伴肺气肿改变。心电图（ 本院）：窦性心动偏速，电轴左偏，完全性右束支传导阻滞，提示左心室肥大，P-R间期延长。血常规（ 本院）：WBC9.4*109/l，N79.9%
初步诊断：慢性阻塞性肺病急性发作
实习医生签名：
带教老师签名：全文翻译（留学生翻译，用词地道）MEDICALRECORDGENERAL INFORMATIONDEPARTMENT: RESPIRATORY MEDICINE
HOSPITALWARD: 17
BEDNUMBER:
HOSPITALIZATIONNUMBER: NAME:×××
OCCUPATION:
RetirementSEX: Male
ADDRESS& PHONE: AGE:
HISTORY PRESENTER: PatientMARITAL STATUS:
CONTACT:PLACE OF ORIGIN:
ADMISSION TIME:
NATIONALITY:
RECORD DATE:Chief Complaint:
Repeatedcough, sputum, with Shortness of breath (asthma) from 30 years, increased from last one day.Historyof Present Illness:Patientfrom nearly 30 years, when the season change from winter to spring appeared repeated cough, sputum, sputum present with large amount of whitemucus, with shortness of breath (asthma) after some activities or someexercise. The symptoms gradually increased. Then the patient was come to our hospital for thetreatment. The patient was diagnosed chronicbronchitis, emphysema, then we gave him anti-infective, eliminating phlegm to smooth wheezingand then after the processing of symptomatic and supportive treatment
the symptoms improved. But again repeated attack of cold, and repeatedcoughing, coughing white mucus phlegm, after one day cold became very serious,with asthma. Then the patient comes to our hospital. In chest X-ray it showedchronic bronchitis, emphysema was changed, so we suggest him to check-in forfurther diagnosis and treatment in our department. The illness in patient withfever, no night sweats, hemoptysis, no chest pain, heart palpitations, noheadache, faint, no belching/eructation, no sour regurgitation, no nausea,vomiting, abdominal pain, abdominal distension, lower extremity edemaunparalleled, spiritual food anorexia, toilet as usual.Past Medical History:Patienthad a history of coronary artery disease &, denied hypertension, history of diabetes &,denied “hepatitis, schistosoma, history of tuberculosis &. No surgery andinjury history. Have penicillin allergy.Systematic reviewHeadand Neck features:
without visual impairment, deafness,tinnitus, vertigo, epitasis, toothache, gingival bleeding and history ofhoarseness.Circulatorysystem:
withoutpalpitations, dyspnea on exertion, pericardial pain, lower extremity edema,ascites, dizziness, headache, syncope, a history of hypertension andrheumatism.
Digestive system:
without belching, acid regurgitation,dysphagia, abdominal pain, and diarrhea, vomiting, jaundice, hematemesis andmelena history.
Genitourinary system: No urinaryfrequency, urgency, dysuria, flank pain, hematuria, urine abnormalities,difficulty urinating, blood pressure, history of facial edema.
Hematopoietic system:
withoutpale skin, dizziness, vertigo, tinnitus, memory loss, heart palpitations, soretongue, skin and mucous membrane bleeding, jaundice, lymph nodes andhepatosplenomegaly, bone pain history.Endocrine and metabolicsystems:
without heat intolerance, sweating, fatigue,headache, visual disturbances, polydipsia, polyuria, edema, significant obesityor significant weight loss history. No increase or loss of hair, pigmentation,sexual function changes.Musculoskeletal system:
No joint pain, joint swelling, jointdeformities, limb movement disorder and weakness, muscle atrophy.Nervous system: no headaches,fainting, memory loss, language disorders, insomnia, disturbance ofconsciousness, paresthesia, paralysis, convulsions.Mental state: withouthallucinations, delusions, disorientation, mood disorders history.Personal history :
long-term living in the country of origin ofbirth, no &schistosomiasis, malaria,& history of exposure tocontaminated water, no alcohol and special hobby, no &dust, toxicsubstances,& Obstetrical history: marriage age,marital medical examination. 5-6
Family history:
no history of genetic diseases and infectiousdiseases.PHYSICAL EXAMINATIONT:37.4oC
Pulse: 95 beats / min
Respiratory: 21 times / min
BP:160/75mmHgGeneral condition:
normal development, eutrophic, normalbody shape, conscious, spirit is poor, medium nutrition, irritability, hands,limbs, tamper with co-operative examination, facial flushing. Automatic postures, screeningcooperationSkin and Mucous Membrane: systemic skin mucous membrane withoutyellow dye, erythema, rash and pigmentation.Lymph glands: Systemic shallow lymph node enlargementand not palpable.Head and Skull :
normal head shape, haircolor black, shiny, normaldistribution, uniform luster, and head no scarring. Eye: eyelids no edema, no bleeding fromconjunctiva, sclera jaundice-free, transparent cornea, bilateral and otherlarge and round pupil diameter of 3mm, sensitivity to light reflection.Ear: No pyorrhea (pus) and papillary tenderness, normalhearing.Nose: nasal patency, septaldeviation and, no runny nose, maxillary sinus and frontal sinus withouttenderness.Mouth:labial red, no cyanosis, teeth in order, no redness pyorrhea no swelling gums, pus, tonsil normal noswelling, no hoarse voice.Neck: without resistance, bilaterally symmetrical, no jugular veinengorgement, and carotid artery pulse can be seen, the middle trachea, thyroidnot enlarged.Chest:
thoracic is symmetrical, Pectoral type breathing mainly, normal breathing rhythm.Lungs:Inspection:Respiratory movements on both sides are equal, barrelchest.Palpation: breathe on both sides of equal mobility, reduce tremor onboth sides of the language, nopleural friction feeling..Percussion: opaque,lung had unvoiced systolic verticalsclavicle on the midline between the fifth rib, shoulder line 9 ribs, left shoulder line between the first 10ribs, lungs mobility of the lower bound of degrees about4cm.Auscultation : low breath sounds of both lungs smells and low scattered on dryrales sound.Heart:Inspection: no pericardial bulge, the apex beat in the left 5th intercostalspace mid clavicular line within 1.0cm. Pulse range of about 1.5cm in diameterPalpation: apex without tremor,friction sensitivity and the lifting of the beat, apex beat position above.Percussion: the relative cardiacdullness boundary is as follows:
Right side（cm）
Intercostal space
Left side （cm）
8Midclavicular line and the distance between thecenter line before the 9 cmAuscultation: heart rate 95 beats /min, heart rate and tidy, the first heart sound normal, the valve auscultationarea pathological murmur about inadequate.Radialartery: a strong beat, rhythm andtidy, no odd pulse or pulse shortage, blood vessel wall elasticity of normal,pulse rate 120 beats / min.Peripheral vascular symptoms: nocapillary pulsation and shooting
sound. Abdomen:Inspection: symmetrical abdomen, noabdominal varicose vein , non-intestinal and gastric peristalsis wave.Palpitation: soft abdomen, notenderness, rebound tenderness, liver, spleen and kidney was notpalpable.Percussion: no shifting dullness,dullness in the lower abdomen was consonant.Auscultation: bowel sounds are notheard, within 1 minute.Anusand rectum: no anal fissure, rectalprolapse, fistulas and hemorrhoids, normal digital rectal examination found nomass, did not find neoplasm , no stenosis, without anarrow and
tenderness.External genital Organs: notexaminedSpineand limbs: the normal spine, limbs, nodeformity, no swelling, joint activities are not limited, no abnormal muscletone.Nervous system: checking does notmatch the limbs muscle strength, muscle tension symmetry. Ther lower extremity Pakistan's signwas not elicited.Specialized examination:
conscious, spiritual difference, no lips cyanosis, tracheal center,barrel chest, both sides of the tactile language to reduced sound chatter, percussion was too voiceless,lungs breath sounds low, smells, and low scattered in the dry rales sound.LABORATORY AND EQUIPMENT DIAGNOSISChest radiograph ( inspection NO: ): chronic bronchitis with emphysema.Electrocardiogram ( in hospital):partial sinus heart rate, left axisdeviation, complete right bundle branch block, suggesting left ventricularhypertrophy, PR interval prolongation.
Routine bloodtest ( in hospital): WBC9.4x109 / l, N79.9 %
AbstractPatient
××× Male, 82years old, because of & repeated cough,sputum, with Shortness of breath (asthma) from 30 years, increased from last one day. Patient had ahistory of coronary artery disease &, denied hypertension, history of diabetes &, denied“hepatitis, history of tuberculosis &. history. Have penicillin allergy.Patient nearly from last 30 years, When the season change from winter to
spring appeared repeated
cough, sputum, sputum present with
large amount of white mucus, with shortnessof breath(asthma) after some activities or some exercise. The symptomsgradually increased. Then the patient was come to our hospital for thetreatment. The patient was diagnosed chronic bronchitis, emphysema, then wegave him anti-infective, eliminating phlegm to smooth wheezing and then afterthe processing of symptomatic and supportive treatment
the symptoms improved. But again repeatedattack of cold, and repeated coughing, coughing white mucus phlegm, after oneday cold became very serious, with asthma. Then the patient comes to ourhospital. In chest X-ray it showed chronic bronchitis, emphysema was changed,so we suggest him to check-in for further diagnosis and treatment in ourdepartment. The illness in patient with fever, no night sweats, hemoptysis, nochest pain, heart palpitations, no headache, faint, no belching/eructation, nosour regurgitation, no nausea, vomiting, abdominal pain, abdominal distension,lower extremity edema unparalleled, spiritual food anorexia, toilet as usual.Admission examination: T: 37.4oC, P: 95 times / min, R: 21 times / min, BP:160/75mmHg conscious, the spirit of poor, non-cyanotic lips, middle trachea,barrel chest, both sides of the tactile language flutter reduction, percussionwas too voiceless, lungs breath sounds low, smell, and scattered in the dryrales sound. Heart rate 95 beats / min, the law together, did not hear andpathological murmurs. Full Chest X-ray:chronic bronchitis with emphysema.
ECG:partial sinus heart rate, left axis deviation, complete right bundlebranch block, suggesting left ventricular hypertrophy, PR intervalprolongation. Routine bloodtest: WBC9.4x109 / l, N79.9 %
Initial diagnosis: Acute exacerbation of chronic
obstructive pulmonary disease (COPD)
Coronary heart diseaseIntern’s Signature:
Teacher’s signature:
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hispku edited on
感谢分享！
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Chronic obstructive pulmonary disease - COPD
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roseanne Chronic obstructive pulmonary disease - COPD谢谢您，由于排版错误，Chronic 排上面一行了，已修改。谢谢。
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hispku edited on
看到平喘翻译成Smooth Wheezing的时候，感觉怪怪的，外国友人也会这么翻译？网上查到的是，anti-asthma， preventing asthma
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个人感觉翻译得一般。。。有直译的嫌疑
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我也觉得似乎不是真正的医生写的。
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