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远程会诊界面填写手册(一)

发布者:鑫达医学翻译 发布时间:2016-11-11阅读:

病历翻译是远程会诊的一个重要因素!在远程会诊环节,一定要亲自到某个意向医院的官网去查看相关信息,点击医院的International center或者International patient,进入相应的远程会诊(Second Opinion)界面,根据网页内容填写信息。远程会诊的界面其实比较简单,跟国内外预约类似。进入界面后,大致填写患者信息,如性别、年龄、生日、护照号码等。此外,还需要填写患者病情(Medical records)及其他附加信息等。不同医院的界面有所不同,但基本类似。
下面借助DANA-FARBER医院的远程会诊界面进行说明:

通过界面可以看出,界面相对简单,对于一名有英语基础的人来说,并不麻烦,而且也不涉及多么麻烦的术语,每一项准备的材料也会有基本的说明。
在这些众多的界面中,患者及家属感觉最棘手的恐怕是Medical Recods的内容填写了,不用担心,可大胆复制既往病历的出院小结,或自己做的病情陈述。病情陈述是对所有病历的陈述与总结,并不麻烦,可以将出院小结简单累加,前提是不遗漏任何的诊疗信息。您无需担心,信息太少医生看了不明白病情,因为在下面的界面中会有界面让上传相应的详细材料。所以,远程会诊的填写非常简单。当然,填写者必须有相关的英文基础,这在我们国家并不是什么难事。
 
翻译远程会诊的病历,最关键的是要有相当的病历翻译经验,译者一定要有牢固的医学背景。下面列举几个翻译样例,仅供大家参考。

原文:
现病史:患者约20天前因右侧肾癌于我科住院治疗,于2015年6月9日在全麻下行腹腔镜右肾部 分切除术.术后一般情况较好, 应用自介素药物治疗. 患者无发热,无腰腹部疼痛,无明显肉眼血 尿。今到我科后续行细胞生物治疗.患者病后精神状态一般,食欲一般,睡眠良好,大便正常,小 便正常,体力情况良好,体重无明显变化。

译文:
History of present illness:
The patient presented to our department 20 days ago due to renal carcinoma (right side). Right sided nephrectomy was performed under laparoscope after general anesthesia on Jun. 9, 2015. The surgery was successfully performed, and the postoperative recovery was satisfactory after administration of interleukin. The patient showed no fever, pain in abdomen or lumbar. No obvious macroscopic hematuria was observed. Now, the patient presented to our department for cellular therapy. Since the onset of the disease, the patient showed no aberrant changes in the sleeping and appetite, as well as the urination and defecation. No obvious change was noticed in the body weight. 

原文:
入院病情摘要:
(1)老年男性患者,右肾部分切除术后20天,入院后续治疗.
(2)患者约20天前因右侧肾癌于我科住院治疗,于2015年6月9日在全麻下行腹腔镜右肾部分切除术.术后一般 情况较好,应用白介素药物治疗.患者无发热,无腰腹部疼痛,无明显肉眼血尿。今到我科后续行细胞生物治 疗.患者病后精神状态一般,食欲一般,睡眠良好,大便正常,小便正常,体力情况良好,体重无明显变化。
(3)查体:T 36.4°C, P 80次/分, R 20次/分,Bp 142 / 84mmHg 双肾区无叩痛,双侧输尿管径路无压痛,膀胱 区无压痛。
入院诊断:1.右肾癌2.右肾部分切除术后3.双肾囊肿4.左侧肾上腺结节5,髙血压

译文:
Admitting conditions:
(1) The aged male patient presented to our department with postoperative changes (20 days) of right-sidednephrectomy for further treatment. 
(2) About 20 days ago, the patient was admitted to our department due to renal carcinoma (right side).  Right sided nephrectomy was performed under laparoscope after general anesthesia on Jun. 9, 2015. The surgery was successfully performed, and the postoperative recovery was satisfactory after administration of interleukin. The patient showed no fever, pain in abdomen or lumbar. No obvious macroscopic hematuria was observed. Now, the patient presented to our department for cellular therapy. Since the onset of the disease, the patient showed no aberrant changes in the sleeping and appetite, as well as the urination and defecation. No obvious change was noticed in the body weight.
(3) Physical examination: Temperature: 36.4°C  Pulse: 80 bpm   Respiration: 20  Blood pressure: 142/84 mmHg. No percussion pain was noticed in both kidneys. Besides, no tenderness was reported by the patient in the bilateral ureter and bladder.
Admitting diagnosis:
1. Renal carcinoma (right side).
2. Postoperative changes of right sided nephrectomy. 
3. Bilateral renal cysts.
4. Nodular lesions in the left adrenal gland.
5. Hypertension.



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