病例 注意
病历 作为出国看病的基本依据，应当引起医学 工作者的严肃对待。译者不但要完全明白病历意思，更要以合理的逻辑思维及语言表达来表述病历内容。病历 主要涉及CT、MRI检查、生化检查、出院小结、入院记录等。所有这些内容都要求准确 ，不能出现乱译的现象。但有时候，会因为中文与英文的表述习惯，出现一定的字面偏颇。根据知情同意的原则， 公司有必要进行书面描述，以避免不必要的理解错误。下面列举一个病历 样例：
History of present illness: On October 23, 2012, physical examinations revealed that the patient’s serum creatinine was 278umol / L, hematuria was + +, proteinuria was + +. Subsequently, she was treated at Peking University First Hospital on November 14, 2012, and her blood pressure was 140/90mmHg. Blood IgA was 3.93g / L, and 24-hour urinary protein was 2.97 g (urine volume 1500 mL). Microscopy for urine red blood cell phase difference revealed a high red blood cell distortion rate. Bilateral renal B ultrasound showed a slightly smaller right kidney, and the renal parenchyma was slightly thin. She was admitted to hospital for treatment, and carried out a renal biopsy. The pathologic report revealed crescentic IgA nephropathy (moderate to advanced).
During the hospitalization, the serum creatinine, blood uric acid, and hemoglobin were 390.6 umol/L, 499 umol/L, and 93 g/L, respectively. She was diagnosed with chronic glomerulonephritis, crescentic IgA nephropathy (moderate to advanced), renal anemia, renal hypertension, and hyperuricemia. Thus, treatments including hypertension-relieving and anemia-correction were given. The patient's condition was stable after discharge. Oral administration of allopurinol was recommended (2 tablets each time, t.i.d.). After 2 weeks, the recheck of blood biochemical indexes was performed, which showed the levels of alanine aminotransferase, aspartate aminotransferase, albumin, and serum creatinine were 52 IU/L, 71 IU/L, 33.2g/L, and 55 umol L, respectively. Meanwhile, systemic red rash was reported. Subsequently, she was admitted to our department. As she was speculated to suffer from acute exacerbation of chronic renal insufficiency, acute drug-induced liver injury, drug-induced dermatitis, symptomatic treatments including administration of hormones, liver-protection, renal function protection were performed accordingly. She was discharged after her condition was improved. At this time, she was admitted to our department to adjust the amount of hormone. Presently, the patient's condition is stable with satisfactory mental condition and appetite. The patient reported no cough or expectoration. Additionally, no painful swelling of joint or fever was reported. No abnormality was observed in the defecation and urination. No significant changes were noted in her body weight.
