英文门诊病历，我行我可以

本科学历，门诊偶尔有外国人就诊，虽然N年前大学英语4级，但我也要尽量与洋人直接交流，写英文病历。

每次专家门诊，自觉写一份英文门诊病历。说个笑话，有一次给一个本地老头写了份英文电子病历，病人下一楼打印，一看全是洋文，气得说：写英文欺侮我老头看不懂啊？

后来我就写双语门诊病历，病人也没有意见了。

平时看书，我看到金句，我尽量贴上来，没事读背一下，温故而知新。

A 40-year-old Caucasian male smoker presented with malaise.

40岁的高加索吸烟男子因不适就诊。

信息量很大的一句话。

He mentioned feeling like this for the past three months but not as severe as when he was admitted.

提及此不适已有3月，先前没有这么严重。

He did not mention any chest pain, heaviness, or pressure.

He did not mention any，此处可直接翻译为“无”

He also denied odynophagia, dysphagia, hematemesis,

He also denied可翻译为“否认”

He denied any alcohol or substance abuse.

否认酗酒及滥用药物。

His past medical history included: Type 2 diabetes mellitus

past medical history，PMH，既往史

His past surgeries included a cholecystectomy

手术史

His home medications included metformin(1,000 mg twice a day),

目前用药情况。。。

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再说个笑话，有一次来了一对印度小夫妻，老公会讲中文，老婆讲英文，我英文问病史，老公用中文回答，好累啊。

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2020-2-29 今天出生的娃有点悲惨，四年过一次生日

A 34-year-old male without any significant past medical history presented with the complaint of shortness of breath, fever, chills, and cough with mucoid sputum for a 6-day duration.

34岁男性，既往体健，主诉气短、发热畏寒、咳嗽咳粘液痰6天。