病历翻译示例

有不少患者家属找我们翻译病历的时候，希望我们可以提供以前翻译的病历，查看翻译质量。不过我们都是予以拒绝的。因为别人的病史资料都是属于个人隐私，没法给无关第三方查看的。

不过鉴于很多患者家属提出了这种要求，我们从网上找到了公开的病历试译，供参考翻译质量。 以下这段中文来源于公开来源：中华医学会病理学分会第二十一次学术会议暨第五届中国病理年会 - 读片会 https://med.motic.com/seminar/index.html

病史：患者，男，17岁，以“体检发现腹膜后肿物3天”为主诉入院。全腹彩超：腹膜后混合性回声区（囊性为主），与右肾中上段、右肝关系密切，考虑来源于右肾可能性大；肝、胆、胰、脾未见明显异常；门静脉血流显像好。中上腹部磁共振平扫+增强：右侧上中腹部巨大占位，考虑来源于右肾-囊性肾癌。大体：右肾：大小25*19*10cm，切面见肿物呈囊性，大小为7*5*4.0cm，囊内容物血性液体，肿物囊壁部分见钙化，实性部分呈灰白、灰红，质地脆，周围残余少量正常肾组织，肾门未见明显淋巴结。右肾上腺：组织一块，大小5*3*2.5cm，切面呈囊实性、暗褐色。右腹膜后淋巴结：找到淋巴结4枚。

MEDICAL HISTORY: The patient is a 17-year-old male. He was admitted to our hospital with the chief complaint of "a retroperitoneal mass discovered during a physical examination 3 days ago." A complete abdominal ultrasound using color Doppler revealed a mixed echogenic (mainly cystic) area in the retroperitoneal region. The mass was very close to the upper third and middle third of the right kidney and the right lobe of the liver, likely originating from the right kidney. No obvious abnormalities were observed in the liver, gallbladder, pancreas, or spleen. Blood flow in the portal vein was clearly visible. Unenhanced and enhanced MRI scans of the middle-upper abdomen identified a large space-occupying mass in the right-sided middle-upper abdomen, which was considered a cystic carcinoma of the right kidney. Gross pathology showed that the right kidney measured 25x19x10 cm. The cut surface revealed a 7x5x4 cm cystic mass filled with bloody fluid and a partially calcified cystic wall. The solid portion of the cystic mass was gray and gray-red with a crisp texture. A small amount of normal residual renal tissue was found surrounding the mass. No obvious lymph nodes were present at the right renal hilum. The right adrenal gland was a 5x3x2.5 cm tissue with a cystic-solid cut surface and a dark brown color. Four right retroperitoneal lymph nodes were found.

以下这段中文来自公开来源，北医三院的病例讨论。 http://www.puh3.net.cn/hxnk/bltl/19276.shtml

查体：Bp150/100mmhg，浅表淋巴结未及肿大，双肺呼吸音清，未闻及干湿性罗音，心律齐，未闻及杂音，腹软，无压痛，双下肢无水肿。 初步诊断：纵膈淋巴结肿大待查 腹部CT：肝内多发病变，性质待定，脓肿，转移瘤？必要时MRI，腹膜后多发小淋巴结。B超示双锁骨上及双颈部多发淋巴结（结构大致正常）。

Physical Examination: BP: 150/100 mmHg. No swollen superficial lymph nodes were detected upon palpation. Breath sounds in both lungs were normal and clear, with no moist or dry rales present. The patient's heart rhythm was regular, and no heart murmurs were detected. The abdomen was soft, without any tenderness. There was no edema in either lower extremity.

Initial Diagnosis: Mediastinal lymph node enlargement, to be further investigated.

Abdominal CT: Multiple intrahepatic lesions were observed, warranting further investigation. Possible abscess or metastases? If necessary, an MRI can be performed. Multiple small retroperitoneal lymph nodes were discovered. B-scan ultrasonography revealed multiple lymph nodes in the bilateral supraclavicular and bilateral neck regions, with generally normal structures.

另外插一句，很多患者及家属搞不清楚哪些检查报告、哪些手术记录需要翻译，可以参考这个网页。 https://www.douban.com/note/708162799/ 。

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