1、病歷的語言特點(diǎn)及其英譯1Abstract：Documentation of medical records requires professional knowledge, which is also the basis for medical translation. Centering on medical terminology and anatomicalntmkl結(jié)構(gòu)（上）的，解剖的 logic, this article, by way of examples, discuses Chinese to English translation skills at lexical, s

2、yntactical grammatical, and textual levels. It is hoped thatthese skills will help translators produce English versions of medical records up to the standards and norms of this professionKey Words: medical records, translation, medical terminology2摘要:病歷的書寫和翻譯有著很強(qiáng)的專業(yè)性,因此,從事病歷翻譯首先要有深厚的醫(yī)學(xué)專業(yè)基礎(chǔ)知識(shí)。本文圍繞專業(yè)術(shù)

3、語及專業(yè)內(nèi)在邏輯這兩個(gè)翻譯核心,從詞匯、句法、語法特點(diǎn)、篇章結(jié)構(gòu)等角度,用實(shí)例分析病歷的漢譯英技巧,試圖使翻譯的病歷更加符合標(biāo)準(zhǔn)和專業(yè)規(guī)范。關(guān)鍵詞:病歷,翻譯,醫(yī)療術(shù)語3 病歷對(duì)醫(yī)療、預(yù)防、教學(xué)、科研、醫(yī)院管理等都有重要的作用。病歷包括門診記錄、入院記錄、入院病歷、病程記錄、手術(shù)記錄、出院記錄、轉(zhuǎn)院記錄等。由于病歷具有極強(qiáng)的專業(yè)性以及自身的語言特點(diǎn), 不經(jīng)過專門學(xué)習(xí),很難產(chǎn)生符合規(guī)范的英語病歷。4為了保障醫(yī)療質(zhì)量和安全,各國(guó)對(duì)醫(yī)療機(jī) 構(gòu)的病歷書寫行為有著詳細(xì)的規(guī)范。我國(guó)衛(wèi)生部2002年頒布了“病歷書寫基本規(guī)范(試行)本”,2010年3月1日起執(zhí)行新修訂的“病歷書寫基本規(guī)范”。我國(guó)病歷書寫規(guī)范基

4、本上沿襲歐美等發(fā)達(dá)國(guó)家,因此,譯者應(yīng)了解病歷譯入國(guó)(如美國(guó))的病歷規(guī)范。5美國(guó)醫(yī)學(xué)會(huì)每年出版Current procedural terminology codes 簡(jiǎn)稱CPT (通用醫(yī)療術(shù)語)規(guī)范醫(yī)療、手術(shù)、診斷術(shù)語的使用。世界衛(wèi)生組織WHO定期審定出版the international classification of disease(國(guó)際疾病分類),統(tǒng)一疾病的名稱及其代碼,目前通用的是2007年第10次修訂版,即ICD-10。6病歷的語言特點(diǎn)及其英譯 病歷檔案有其獨(dú)特的語言現(xiàn)象,如包含很多醫(yī)學(xué)專業(yè)術(shù)語,經(jīng)常使用縮略語和縮寫代號(hào),使用省略句、簡(jiǎn)潔句和以解剖學(xué)邏輯為基礎(chǔ) 的長(zhǎng)句(多為被動(dòng)句

5、或復(fù)合句)。接下來，將從上述幾個(gè)方面探討醫(yī)療病歷的英譯方法。71病歷術(shù)語及縮略語11專業(yè)術(shù)語 病歷的記錄內(nèi)容主要包括疾病檢查、診斷、治療、手術(shù)過程。其中,疾病檢查和診斷主要內(nèi)容都比較接近,因此專業(yè)術(shù)語不多,比較固定;而手術(shù)過程涉及各個(gè)器官系統(tǒng),專業(yè)術(shù)語主要是解剖學(xué)術(shù)語,比較廣泛。由于拉丁語是對(duì)自然科學(xué)影響深遠(yuǎn)的語言,早在1895年,世界各國(guó)的醫(yī)務(wù)工作人員就共同商定,拉丁語為國(guó)際醫(yī)學(xué)活動(dòng)中的通用語言,正規(guī)的醫(yī)藥術(shù)語名稱及處方均用拉丁語書寫。很多醫(yī)學(xué)專業(yè)術(shù)語是由拉丁詞根衍生而來。隨著醫(yī)學(xué)在近代的興盛,很多專業(yè)術(shù)語有了相應(yīng)的英語詞匯,如表1。因此,一個(gè)中文醫(yī)學(xué)專業(yè)術(shù)語常有多個(gè)對(duì)應(yīng)的英語及拉丁語詞匯,

6、到底該選哪個(gè)最恰當(dāng)?由于病歷的讀者要兼顧非專業(yè)的患者及其家屬、保險(xiǎn)業(yè)人員,因此,在表達(dá)上盡量選用通俗些的術(shù)語。在病歷漢譯英時(shí),如果某個(gè)專業(yè)術(shù)語可以用英語表達(dá),則通常選用英語詞匯。8912縮略語為了節(jié)省篇幅和時(shí)間,病歷中縮略語用得較多,如大三陽、兩對(duì)半、神清等,有的縮略語是專業(yè)術(shù)語,有的是省略句,略舉數(shù)例見表2。1011122以解剖學(xué)邏輯關(guān)系為基礎(chǔ)的長(zhǎng)句在通常情況下,英語長(zhǎng)句多,漢語短句多。而病歷的手術(shù)記錄中,由于手術(shù)的連續(xù)性,漢語常有一些比英語還長(zhǎng)的句子,有時(shí)甚至是“一逗到底”,即一個(gè)段落全是逗號(hào),結(jié)尾一個(gè)句號(hào)。在翻譯時(shí)需要適當(dāng)斷句。這種斷句處理不是盲目的,而是要根據(jù)解剖學(xué)的邏輯關(guān)系,適當(dāng)科學(xué)

7、地處理。現(xiàn)略舉幾例:13(1)返納腫物壓住內(nèi)環(huán)口,腫物不出現(xiàn),囑患者咳嗽時(shí)內(nèi)環(huán)處有沖擊感。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腹股溝的 ring14(2)術(shù)后病理: (乙狀結(jié)腸)隆起型中分化管狀-絨毛狀腺癌,侵及腸壁全層,上、下切端凈。Pathologicalpl

8、dkl 醫(yī)病理學(xué)的；由疾病引起的；病態(tài)的，疾病的 results after operation revealed bulged(隆起的) medium-differentiated,（中分化） ductal醫(yī) 管的，導(dǎo)管的 -villous絨毛狀的，有絨毛的adeno（腺）-carcinoma（癌，惡性腫瘤，cancer） of the sigmoidS形的，C形的 colon（冒號(hào)，結(jié)腸）, infiltrating to all the layers of the colonwallBoth the upper excision end and the lower excision en

9、d were free from carcinoma.15(3)由膽囊底開始切開膽囊漿膜,用電刀凝切膽囊與肝臟之間的附著,將膽囊從膽囊床游離,確認(rèn)膽囊管與膽總管之間的關(guān)系后,切斷膽囊管,將膽囊切除,膽囊管殘端加縫扎一道,標(biāo)本示家屬后送術(shù)中冰凍病理。The cysticsstk adj.胞囊的，膀胱的，serosasros, -z漿膜，絨（毛）膜 was cut apart from the cystic bottom, with the adhesion between the liver and16 the gallbladder cut apart and coagulatedkojlet

10、凝固；使結(jié)塊，使變稠 by electric knife. The gall bladder was separated from the cystic bed. After the connection between the cystic duct膽囊管and common bile duct(膽總管) was verified（確認(rèn)）, the cystic duct severed, the gall bladder was excisedksaz 切除 and removed（切斷膽囊管,將膽囊切除.） The residual rzdul end of the cystic duc

11、t was suturedsut 縫傷口 and ligatedlaet 結(jié)扎，綁, with the excised specimen being verified by the patients relatives and submitted to frost pathology膽囊管殘端加縫扎一道,標(biāo)本示家屬后送術(shù)中冰凍病理.17(4)右側(cè)肩部腫脹,右鎖骨畸形,局部壓痛明顯,可捫及骨擦感,右肩關(guān)節(jié)各向活動(dòng)受限,右前臂及右手各指活動(dòng)自如,無明顯受限,右橈動(dòng)脈可捫及搏動(dòng),右手末端血供尚好,指壓甲床紅潤(rùn)。The right shoulder is swollen, with the right

12、 clavicleklvkl鎖骨 deformed and obvious local tenderness. Bony crepitus拉腸排氣，屁；咿軋音；捻發(fā)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.這里有一家

13、餐館，你付一定的錢隨便吃。)without obvious limits .Pulse in the right radial redil輻射狀的； artery is palpable, with norm blood supply in the acrakr 肢端 of the right hand and redness in the nails after press18此外,中文病歷中有些有內(nèi)在邏輯關(guān)系的零碎詞句可以通過英語樹杈句的粘合功能組合成復(fù)合句。現(xiàn)舉幾例:(5)患者林水珍,女, 54歲,以“咽部不適感1個(gè)月”為主訴于2007年2月12日入院。 The 54-year-old

14、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)患者陳淑金,女, 65歲,第三次來本院就診,過去四五周來前胸刺痛,主要發(fā)生在運(yùn)動(dòng)時(shí),躺下或坐起時(shí)加劇。This is the third office visit for this 65-year-old female, named Chen Shujin, who for the pas

15、t 4-5 weeks has been having significant sharp stabbing pains of her anterior chest primarily with movement， especially when lying down or sitting up193省略句病歷英文與漢語很相似的一個(gè)現(xiàn)象是簡(jiǎn)單句較多,基本按邏輯順序排列成流水句,且省略句子成分很多見,如省略謂語、主語甚至主謂全省略掉。這種情況主要見于入院查體及病程記錄中。由于這種入院查體及病程記錄通常涉及多個(gè)系統(tǒng)的檢查,而句型基本為“主語+be +表語”,主語為體檢的項(xiàng)目或系統(tǒng),表語為名詞性結(jié)果

16、,句子極短,三五個(gè)字即成一句,相同的謂語be在后面各句省略;或直接用冒號(hào)連接主語(體檢項(xiàng)目)和賓語(體檢結(jié)果),現(xiàn)舉幾例:20(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.體溫986 (F),脈博88,呼吸16,血壓110/60,體重130,身高168。心律正常,無雜音。21(2) 47-year-old femal

17、e 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發(fā)紺(紺青 gnqng) ，蒼白病，黃萎病 , or edema idim醫(yī)】浮腫;水腫 (患者)女性, 47歲,無急性病痛癥狀。雙眼等大,瞳孔圓形,有光反應(yīng)。穿著護(hù)膝。雙

18、肺音清。心率正常。腹軟。四肢無杵狀變,無發(fā)紺或水腫。22(3 ) PHYSICAL EXAMINATION: Chest: clear to auscultation：sk!ten 【醫(yī)】聽診(法);聽 and percussion. Heart: Regular rate and rhythm. Abdomen: Soft ,nontender醫(yī)非柔嫩的，非敏感的，非觸痛的，無觸痛的 without distention.膨脹，延伸 (detention拘留，扣押；阻留；放學(xué)后留校；（非法）占有)查體:雙肺聽診及叩診音清。心律正常。腹軟,無壓痛及脹氣。23在英文病歷書寫規(guī)范里,還可見到一些主

19、謂全都省掉、只表述結(jié)果的不完整句子,完全是中文的句法,這是沒有見過英文規(guī)范病歷的譯者不敢冒險(xiǎn)的。如:(4) Patient is a bilateral lower leg amputee. Currently confined to wheelchair(病人雙下肢截肢,只能坐在輪椅里。)(5) Follow-up visit using relaxation and atenolol阿替洛爾，氨酰心安 .Still with severe headache pain. Feeling more steady on his feet. No chest pain or shortness o

20、f breathStill with severe head and face pain.Still stating symptoms change with weather, today a particularly bad day(復(fù)診:病人在服用降壓藥和阿替洛爾。頭痛仍很劇烈。但感覺腿腳平穩(wěn)。無胸痛氣短。頭痛和臉部疼痛照舊,病人主訴疼痛隨天氣變化,今天尤其難受。)24(6) Well-developed, well-nourished child who is lethargicle:dik and pale(病人為兒童,發(fā)育良好,營(yíng)養(yǎng)狀態(tài)佳,沒精打彩,臉色蒼白。)有時(shí)省掉主語,類似于中

21、文的無主句。如:(7) Cranial Nerves are intact. Moves all upper extremities on command without difficulty(顱神經(jīng)未受損。能隨意自如地活動(dòng)雙側(cè)上肢。)(8) Patient will open his eyes to name only. Does not answer any questions.(病人只在聽見自己名字時(shí)才睜眼。不愿回答任何問題。)25此外,出院醫(yī)囑也常不用完整的句子而用名詞短語、不定式短語等,如:(9) Return visit in 3 days for packing removal(

22、3天后復(fù)診拆線。)(10) Patient to continue on Zantac 300 mg tid(繼續(xù)服用甲胺呋硫, 300mg,一日三次)有必要指出,上述省略句式通常見于入院查體及常規(guī)查房記錄中。手術(shù)記錄比較正式,通常要求完整的句法結(jié)構(gòu)。264病歷英語的時(shí)態(tài)41門診病歷及常規(guī)查房記錄時(shí)態(tài)用一般現(xiàn)在時(shí)。但有明確的時(shí)間狀語的句子則仍用相應(yīng)的時(shí)態(tài)。如This is an established patient who has been complaining of left waist pain for approximately 1 year (該病人為既往病人,主訴左腰疼約有1年。

23、)2742手術(shù)記錄用一般過去時(shí)。如An incision was made overlying this large ganglionlin cystand dissection was carried down until the cyst was encountered(在該腱鞘囊腫外的皮膚上作一切口,往下分離直到囊腫。)43病理檢查報(bào)告用一般現(xiàn)在時(shí),對(duì)所接收到的標(biāo)本的病理性狀進(jìn)行客觀描述。如The inner wall of the cyst is smooth, with the surrounding glands thickening equally in sheet of gra

24、y color and moderate hardness.(囊內(nèi)壁光滑,周圍乳腺片狀均勻增厚,灰白,質(zhì)中。)283病歷的篇章結(jié)構(gòu)特點(diǎn)綜觀中國(guó)醫(yī)生書寫的病歷和美國(guó)的病歷規(guī)范,兩者在篇章結(jié)構(gòu)上最大的不同是在查體及出院小結(jié)的段落劃分上。中文病歷的出院記錄中,其住院經(jīng)過全部就一段,從主訴到入院,從查體到簡(jiǎn)要手術(shù)過程,再到出院,全部囊括于一段,因此,段落臃腫,不直觀,不方便查閱。而英文的出院小結(jié)及查體等內(nèi)容段落短小精悍,基本上一個(gè)段落就三兩個(gè)句子(且多為省略句),因此,僅查體一個(gè)內(nèi)容通常就有很多小段落,體檢的項(xiàng)目一目了然,十分直觀。因此,中譯英時(shí),要注意按照邏輯關(guān)系和意群適當(dāng)分段。如:29(1) PH

25、YSICAL 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濕羅音指由于吸氣時(shí)，氣體通過呼吸道內(nèi)的分泌物如滲出液，痰液，血液黏液和膿液等，形成的水泡，破裂所產(chǎn)生的聲音，或由于小支氣

26、管壁因分泌物粘著而陷閉，當(dāng)吸氣時(shí)，突然張開重新充氣所產(chǎn)生的爆裂音。 appreciated.Clear to auscultationCardiovascular: Normal sinussans竇，竇道 rhythm. No murmurs30查體:患者,男,發(fā)育良好,營(yíng)養(yǎng)狀況佳,情緒低落,并不特別痛苦。血壓128/75,脈博90,正常有力。體溫正常。身高:180cm。頸軟,無腫物。呼吸正常,無哮喘或干濕羅音,呼吸音清。心血管系統(tǒng)正常,竇性心律,無雜音。人體右心房上有一個(gè)特殊的小結(jié)節(jié)，由特殊的細(xì)胞構(gòu)成，叫做竇房結(jié)。它可以自動(dòng)地、有節(jié)律地產(chǎn)生電流，電流按傳導(dǎo)組織的順序傳送到心臟的各個(gè)部位，從

27、而引起心肌細(xì)胞的收縮和舒張。人體正常的心跳就是從這里發(fā)出的，這就是“心臟起搏點(diǎn)”。竇房結(jié)每發(fā)生1次沖動(dòng)，心臟就跳動(dòng)1次，在醫(yī)學(xué)上稱為“竇性心律”。所以，心臟正常的跳動(dòng)就應(yīng)該是竇性心律。31(2)病人系因“車禍外傷術(shù)后近3天伴氣促、呼吸困難”入院。查體:發(fā)育正常,營(yíng)養(yǎng)中等,昏迷狀,雙側(cè)瞳孔針尖樣大小,直徑約15mm,光反射消失,經(jīng)口氣管插管,留置經(jīng)鼻胃管。頸軟,雙側(cè)胸腔閉式引流,引流瓶可見氣泡不斷溢出。右側(cè)胸腔引流管留置在右腋中線4、5肋間位置,左側(cè)留置在左鎖骨中線第二肋間,引流管不斷有新鮮血性液體流出,雙上肺呼吸音清晰,可聞少許濕音,心臟 (-),腹肌緊張,右肝下引流管2根,左肝下引流管2根,

28、膀胱直腸凹引流管2根,均見血性液體流出。32The 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 disappeared33Tracheal tube through mouth and gastric tube through noseNeck was supple Closed drainage from both chest cavities.