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病历翻译样例

发布者:鑫达医学翻译 发布时间:2013-03-17 8:50:52 阅读:

原文:
病史/用药史:睡眠欠佳,出汗多,母乳喂养至今,1小时哺乳1次,辅食少,服VD,出生足月,体重3.0kg。卵圆孔未闭。EH史。
PE:体重6.35kg,身长62.9cm头围42cm,前囱2.0cm X 2.0cm,神清,发梢黄,双肺呼吸音稍粗,心律整,心音有力,心前区可闻及II/6SM杂音,柔和,肋外翻+,腹平软,下肢稍弯曲,俯卧位能抬头90度,下肢支撑欠有力。

译文:
Medical history/history of medication
: Poor sleeping and hyperhidrosis was reported. The baby was fed with breast milk once an hour. Few adjunctive foods were taken. Oral administration of vitamin D was given. The oval foramen was not closed prior to the physical check. The baby had history of external hydrocephalus (EH).
Physical check: Body weight: 6.35kg, body length: 62.9cm, head circumference: 42cm, anterior fontanelle: 2.0cm × 2.0cm. The color of the hair was slightly yellow. The breath sounds of both lungs were slightly coarse. The cardiac rhythm was regular. Heart sounds were powerful. 2/6 systolic heart murmur was  auscultated in the precordial region. Rib eversion was identified. The abdomen was flat and soft. The lower extremities were a little bending. She could raise her head to 90 degree in a prone posture. The support of her lower extremities was not powerful.
 


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