病病历的英的英译 病历的书写和翻译有着很强的专业性,因此,从事病历翻译首先要有深厚的医学专业基础知识。本文围绕专业术语及专业内在逻辑这两个翻译核心,从词汇、句法、语法特点、篇章结构等角度,用实例分析病历的汉译英技巧,试图使翻译的病历更加符合标准和专业规范。 病历对医疗、预防、教学、科研、医院管理等都有重要的作用。病历包括门诊记录、入院记录、入院病历、病程记录、手术记录、出院记录、转院记录等。由于病历具有极强的专业性以及自身的语言特点, 不经过专门学习,很难产生符合规范的英语病历。 为了保障医疗质量和安全,各国对医疗机 构的病历书写行为有着详细的规范。我国卫生部2002年颁布了“病历书写基本规范(试行)本”,2010年3月1日起执行新修订的“病历书写基本规范”。我国病历书写规范基本上沿袭欧美等发达国家,因此,译者应了解病历译入国(如美国)的病历规范。 美国医学会每年出版Current procedural terminology codes 简称CPT (通用医疗术语)规范医疗、手术、诊断术语的使用。世界卫生组织WHO定期审定出版the international classification of disease(国际疾病分类),统一疾病的名称及其代码,目前通用的是2007年第10次修订版,即ICD-10。病历的语言特点及其英译 病历档案有其独特的语言现象,如包含很多医学专业术语,经常使用缩略语和缩写代号,使用省略句、简洁句和以解剖学逻辑为基础 的长句(多为被动句或复合句)。接下来，将从上述几个方面探讨医疗病历的英译方法。 1病历术语及缩略语11专业术语 病历的记录内容主要包括疾病检查、诊断、治疗、手术过程。其中,疾病检查和诊断主要内容都比较接近,因此专业术语不多,比较固定;而手术过程涉及各个器官系统,专业术语主要是解剖学术语,比较广泛。由于拉丁语是对自然科学影响深远的语言,早在1895年,世界各国的医务工作人员就共同商定,拉丁语为国际医学活动中的通用语言,正规的医药术语名称及处方均用拉丁语书写。很多医学专业术语是由拉丁词根衍生而来。随着医学在近代的兴盛,很多专业术语有了相应的英语词汇,如表1。因此,一个中文医学专业术语常有多个对应的英语及拉丁语词汇,到底该选哪个最恰当?由于病历的读者要兼顾非专业的患者及其家属、保险业人员,因此,在表达上尽量选用通俗些的术语。在病历汉译英时,如果某个专业术语可以用英语表达,则通常选用英语词汇。 12缩略语为了节省篇幅和时间,病历中缩略语用得较多,如大三阳、两对半、神清等,有的缩略语是专业术语,有的是省略句,略举数例见表2。 2以解剖学逻辑关系为基础的长句在通常情况下,英语长句多,汉语短句多。而病历的手术记录中,由于手术的连续性,汉语常有一些比英语还长的句子,有时甚至是“一逗到底”,即一个段落全是逗号,结尾一个句号。在翻译时需要适当断句。这种断句处理不是盲目的,而是要根据解剖学的逻辑关系,适当科学地处理。现略举几例: (1)返纳肿物压住内环口,肿物不出现,嘱患者咳嗽时内环处有冲击感。If the swelling was pushed back to the internal inguinal ring, it would not appear. When the patient coughed as suggested, the vibrated impulsion was palpable at the internal inguinalwnl腹股沟的腹股沟的 ring (2)术后病理: (乙状结肠)隆起型中分化管状-绒毛状腺癌,侵及肠壁全层,上、下切端净。Pathologicalpldkl 医医病理学的；由病理学的；由疾病引起的；病态的，疾病的疾病引起的；病态的，疾病的 results after operation revealed bulged(隆起的) medium-differentiated,（中分化） ductal医 管的，导管的 -villous绒毛状的，有绒毛的adeno（腺）-carcinoma（癌，恶性肿瘤，cancer） of the sigmoidS形的，形的，C形的形的 colon（冒号，结肠）, infiltrating to all the layers of the colonwallBoth the upper excision end and the lower excision end were free from carcinoma. (3)由胆囊底开始切开胆囊浆膜,用电刀凝切胆囊与肝脏之间的附着,将胆囊从胆囊床游离,确认胆囊管与胆总管之间的关系后,切断胆囊管,将胆囊切除,胆囊管残端加缝扎一道,标本示家属后送术中冰冻病理。The cysticsstk adj.胞囊的，膀胱的，胞囊的，膀胱的，serosasros, -z浆膜，绒（毛）膜浆膜，绒（毛）膜 was cut apart from the cystic bottom, with the adhesion between the liver and the gallbladder cut apart and coagulatedkojlet凝固；使结块，使变稠 by electric knife. The gall bladder was separated from the cystic bed. After the connection between the cystic duct胆囊管and common bile duct(胆总管) was verified（确认）, the cystic duct severed, the gall bladder was excisedksaz 切除 and removed（切断胆囊管,将胆囊切除.） The residual rzdul end of the cystic duct was suturedsut 缝伤口 and ligatedlaet 结扎，绑, with the excised specimen being verified by the patients relatives and submitted to frost pathology胆囊管残端加缝扎一道,标本示家属后送术中冰冻病理. (4)右侧肩部肿胀,右锁骨畸形,局部压痛明显,可扪及骨擦感,右肩关节各向活动受限,右前臂及右手各指活动自如,无明显受限,右桡动脉可扪及搏动,右手末端血供尚好,指压甲床红润。The right shoulder is swollen, with the right clavicleklvkl锁骨锁骨 deformed and obvious local tenderness. Bony crepitus拉肠排气，屁；咿轧音；捻发音 exists when being pressedThe right shoulder joint motion is limited in various directions. The right forearm and every finger of it can move ad-lib, (Here is a restaurant where you pay fixed price and eat adlib.这里有一家餐馆，你付一定的钱随便吃。)without obvious limits .Pulse in the right radial redil辐射状的； artery is palpable, with norm blood supply in the acrakr 肢端 of the right hand and redness in the nails after press 此外,中文病历中有些有内在逻辑关系的零碎词句可以通过英语树杈句的粘合功能组合成复合句。现举几例:(5)患者林水珍,女, 54岁,以“咽部不适感1个月”为主诉于2007年2月12日入院。 The 54-year-old female patient named Lin Shuizhen, is admitted for hospitalization with the major complaint of malaise at the pharynxfriks for one month”on Feb 12, 2007(6)患者陈淑金,女, 65岁,第三次来本院就诊,过去四五周来前胸刺痛,主要发生在运动时,躺下或坐起时加剧。This is the third office visit for this 65-year-old female, named Chen Shujin, who for the past 4-5 weeks has been having significant sharp stabbing pains of her anterior chest primarily with movement， especially when lying down or sitting up 3省略句病历英文与汉语很相似的一个现象是简单句较多,基本按逻辑顺序排列成流水句,且省略句子成分很多见,如省略谓语、主语甚至主谓全省略掉。这种情况主要见于入院查体及病程记录中。由于这种入院查体及病程记录通常涉及多个系统的检查,而句型基本为“主语+be +表语”,主语为体检的项目或系统,表语为名词性结果,句子极短,三五个字即成一句,相同的谓语be在后面各句省略;或直接用冒号连接主语(体检项目)和宾语(体检结果),现举几例: (1) Her temperature is 986 (F), pulse88, respiratoryresprt:ri: rate 16, blood pressure 110/60, weight130, height5 feet 7 inches. Heart regular rate with no murmurs.体温986 (F),脉博88,呼吸16,血压110/60,体重130,身高168。心律正常,无杂音。 (2) 47-year-old female in no acute distress. Eyes PERRLA (pupils equal round and reactive to light accommodation) She is wearing knee braces. Lungs clear. Heart regular. Abdomen：bdmn soft. Extremities without clubbing, cyanosissainusis发绀(绀青 gnqng) ，苍白病，黄萎病 , or edema idim医】浮肿;水肿 (患者)女性, 47岁,无急性病痛症状。双眼等大,瞳孔圆形,有光反应。穿着护膝。双肺音清。心率正常。腹软。四肢无杵状变,无发绀或水肿。 (3 ) PHYSICAL EXAMINATION: Chest: clear to auscultation：sk!ten 【医】听诊(法);听 and percussion. Heart: Regular rate and rhythm. Abdomen: Soft ,nontender医非柔嫩的，非敏感的，非触痛的，无触痛的 without distention.膨膨胀，延伸胀，延伸 (detention拘留，扣押；阻留；放学后拘留，扣押；阻留；放学后留校；（非法）占有留校；（非法）占有)查体:双肺听诊及叩诊音清。心律正常。腹软,无压痛及胀气。 在英文病历书写规范里,还可见到一些主谓全都省掉、只表述结果的不完整句子,完全是中文的句法,这是没有见过英文规范病历的译者不敢冒险的。如:(4) Patient is a bilateral lower leg amputee. Currently confined to wheelchair(病人双下肢截肢,只能坐在轮椅里。)(5) Follow-up visit using relaxation and atenolol阿替洛尔，氨酰心安 .Still with severe headache pain. Feeling more steady on his feet. No chest pain or shortness of breathStill with severe head and face pain.Still stating symptoms change with weather, today a particularly bad day(复诊:病人在服用降压药和阿替洛尔。头痛仍很剧烈。但感觉腿脚平稳。无胸痛气短。头痛和脸部疼痛照旧,病人主诉疼痛随天气变化,今天尤其难受。) (6) Well-developed, well-nourished child who is lethargicle:dik and pale(病人为儿童,发育良好,营养状态佳,没精打彩,脸色苍白。)有时省掉主语,类似于中文的无主句。如:(7) Cranial Nerves are intact. Moves all upper extremities on command without difficulty(颅神经未受损。能随意自如地活动双侧上肢。)(8) Patient will open his eyes to name only. Does not answer any questions.(病人只在听见自己名字时才睁眼。不愿回答任何问题。) 此外,出院医嘱也常不用完整的句子而用名词短语、不定式短语等,如:(9) Return visit in 3 days for packing removal(3天后复诊拆线。)(10) Patient to continue on Zantac 300 mg tid(继续服用甲胺呋硫, 300mg,一日三次)有必要指出,上述省略句式通常见于入院查体及常规查房记录中。手术记录比较正式,通常要求完整的句法结构。 4病历英语的时态41门诊病历及常规查房记录时态用一般现在时。但有明确的时间状语的句子则仍用相应的时态。如This is an established patient who has been complaining of left waist pain for approximately 1 year (该病人为既往病人,主诉左腰疼约有1年。) 42手术记录用一般过去时。如An incision was made overlying this large ganglionlin cystand dissection was carried down until the cyst was encountered(在该腱鞘囊肿外的皮肤上作一切口,往下分离直到囊肿。)43病理检查报告用一般现在时,对所接收到的标本的病理性状进行客观描述。如The inner wall of the cyst is smooth, with the surrounding glands thickening equally in sheet of gray color and moderate hardness.(囊内壁光滑,周围乳腺片状均匀增厚,灰白,质中。) 3病历的篇章结构特点综观中国医生书写的病历和美国的病历规范,两者在篇章结构上最大的不同是在查体及出院小结的段落划分上。中文病历的出院记录中,其住院经过全部就一段,从主诉到入院,从查体到简要手术过程,再到出院,全部囊括于一段,因此,段落臃肿,不直观,不方便查阅。而英文的出院小结及查体等内容段落短小精悍,基本上一个段落就三两个句子(且多为省略句),因此,仅查体一个内容通常就有很多小段落,体检的项目一目了然,十分直观。因此,中译英时,要注意按照逻辑关系和意群适当分段。如: (1) PHYSICAL EXAMINATION:General well-developed, well-nourished,depressed male in no acute distress. BP: 128/75.Pulse: 90, regular and strong.Temperature: normalHeight: 180cmNeck: Supple. No masses.Respiratory: Normal.No wheezes, rales or rhonchi湿罗音指由于吸气时，气体通过呼吸道内的分泌物如渗出液，痰液，血液黏液和脓液等，形成的水泡，破裂所产生的声音，或由于小支气管壁因分泌物粘着而陷闭，当吸气时，突然张开重新充气所产生的爆裂音。 appreciated.Clear to auscultationCardiovascular: Normal sinussans窦，窦道 rhythm. No murmurs 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15mm,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 about15m.Light reflex disappeared Tracheal tube through mouth and gastric tube through noseNeck 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 theupper 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/A1Bicuspid regurgitation is positive (+) during contraction phaseTricuspid regurgitation is positive (+) during contraction phase