Перевод выписки из медицинской карты больного на английский.

Переводчикам очень часто приходиться работать с личными документами клиентов. Сегодня особое место занимает медицинский перевод – довольно сложные документы с наличием разнообразной терминологии специального характера.  Сегодня я предлагаю вашему вниманию перевод выписки из медицинской карты больного на английский.

/Seal: Kyiv municipal clinical hospital of emergency medical care. Kyiv city, Bratyslavska St. 3/   Ministry of Health Protection of Ukraine Name of institution Municipal clinical hospital of emergency medical service (MCHEMS)Code of the form in accordance with Classifier of OfficeEntity code number in accordance with Classifier of Office   Medical documentation (FORM № 027/˳) Approved by degree of the MHC in Ukraine

Extract

from ambulatory, hospital medical record № 00000

(underline)

              To a polyclinic (name and address of the institution submitting the extract)

  1.  Name, surname and patronymic of the patient:
  2. Date of birth: 07/15/82
  3. Home address:
  4. Work place, occupation:         ———————
  5. Dates:    a) in ambulatory care: diseases

Recommendation to transfer to the hospital

b)  in hospital care: hospitalization: 11/24/14

extract, death (underline): 10/25/14

  1. Full diagnosis (basic disease, concomitant amplifications)

Closed craniocerebral injury. Brain commotion. Soft tissues injury of the head and left forearm.

  1. Health record overview, diagnostic testing, development of the disease, treatment provided, state during recommendation for hospitalization and extract: the patient was delivered (by ambulance car) with complaint of (headache, dizziness, nausea, vomiting, weakness)

Injured in the result of/ disease developed

Beating by the unknown persons

General state while being delivered (relatively satisfactory/moderate) in no acute distress. Neurologically: according to the Glasgow Coma Scale – 14 p. consciousness (clear, obscure, semicoma), pupils D=S, active, intractable photoreaction. Nystagmus (absent, ↔, ↕, rolling, small-, middle-, large-swinging

Tendon and periosteal reflexes D=S,/brisk, middle brisk, impaired

Symmetrical face (due to the injury of soft parts)

Subcortical reflexes: absent, (-)          Marinesco-Radovici sign, Gurevich-Mann symptom “ – “

Pathological symptoms (absent)

Meningioma symptoms (absent)

Coordinator test (satisfactory performance, problems with proprioception during Romber testing, approximate falling within

Locally soft tissue injury of the head and left forearm

Laboratory and instrumentally Examined: Helical computed tomography №

Craniography (without bone-traumatic injury)

…Left forearm – without bone-traumatic injury

Consulted by trauma specialist

Surgery

Prescribed conservative (antalgic, antimicrobial, neuroinflammatory, sedative, dehydration, anticonvulsant, vascular, general  tonic, restorative, anti-inflammatory) treatment. Patient’s state has improved, discharged in satisfactory condition for further outpatient treatment under the supervision of a neurologist, surgeon, clinic according to the place of residence, traumatologist.

Medical and work recommendations supervision of a neurologist according to the place of residence

Dated 10/25/14

Attending doctor           [Signature]            Doctor’s Surname

Head of department                                     X X.X.

 /Seal: FOR REFERENCES Kyiv municipal clinical hospital of emergency medical care. Ministry of Health Care, the Board of the Kyiv City Council, Ukraine. Identification code 00164945/
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