将中文病例翻译成英文

TheLord

诉：颈项部疼痛伴双上肢麻木

Sue:

neckpainandupperlimbnumbness

2

2

月余。

Morethanamonth.

现病史：患者素有颈项部疼痛病史，于

History:thepatienthasa

historyof

neckpain,to

2

2

月前无明显诱因出现颈项部疼痛伴双上肢麻木，

Withoutapparentinducementoccurrenceneckpainwithdoubleupperlimbsnumbnessmonthsago,

未予重视

Donotpayattentionto,

休息后症状未见缓解，

Thesymptomswerenotrelievedafterrest,

自服活血止痛药后颈项部疼痛缓解，

Self

service

Huoxue

painkillers

neckpain

relief,

双上肢麻木改善不明显，

Doubleupperlimbsnumbnoobviousimprovement,

停药后复发就诊于武警医院，行颈椎

Relapseafterstopping,visitstotheArmedPoliceHospital,cervicalspine

MRI

MRI

提示：

Prompt.

C6-7

C6-7

椎间盘轻度突出，为求系统治疗，遂于

Discslightlyprominent,forthesakeofthetreatmentsystem,andto

今日就诊我院，门诊以“颈椎病”收住本科。刻下：颈项部疼痛伴双上肢麻木，颈椎活动轻度

Today'svisitinourhospital,

outpatientservicewithcervicalspondylosis

admittedto

undergraduate.At

themoment:neckpainwithdoubleupperlimbsnumbness,mildcervicalactivity

受限双上肢下垂时麻木症状加重，平放时症状减轻，长时间低头及劳累后症状明显加重，休

Limited,

doubleupperlimbs

muscle

numbness

symptoms,whenlaidflattoalleviatethe

symptoms,long

timeheadandexertionalsymptomsincrease,Hugh

息后缓解双上肢肌力无异常，偶见头痛头晕，未见晕厥，无夜间加重，双下肢踩棉花样感不

After

remission,doubleupperlimbsstrengthwithoutexception,I

seenoheadacheand

dizziness,syncope,nonightlyaccentuation,

doublelowerlimbs

onthe

cotton

likenot

feeling

明显纳可，眠安，二便可，舌质红，苔白，脉细数。

Obviously,

nake,Mianan,twocan,

redtongue,mosswhite,pulsecounting.

既往史：否认结核等传染病史及密切接触史。否认药物、食物过敏史。预防接种史不详。

Pasthistory:

denialof

tuberculosisandotherinfectiousdiseasehistoryandhistoryofclosecontact.Denydrug,

food

allergies.Vaccinationhistoryisunknown.

有肝炎病史

Withahistoryofhepatitis

2

2

年。

Years.

个人史：生于原籍，无外地长期居住史，无疫区居住史。平素生活规律，无吸烟史，无毒

Personalhistory:inthecountryoforigin,nofieldoflong-termresidentialhistory,historyoflivinginnonendemicarea.

Usuallythelawof

life,nosmoking,no

物接触史。

Contacthistory.

婚育史：适龄结婚，配偶及子女均健康。

Obstetricalhistory:

ageof

marriage,spouses

andchildren

are

healthy.

体

Body

格

Lattice

检

Check

查

Check

T:36.5

T:36.5

℃

C

P:74

P:74

次

Time

/

/

分

Divided

R:20

R:20

次

Time

/

/

分

Divided

BP:110/80mmHg

BP:110/80mmHg

发育正常营养中等，自动体位，查体合作，神志清楚，回答切题。全身皮肤、粘膜无黄

Thedevelopmentofnormal,nutrientmedium,

automatic

position,checkcooperation,sane,

answertothe

point.Systemicskin,mucousmembranewithoutyellow

染、皮疹及出血点，无肝掌、蜘蛛痣，浅表淋巴结未触及肿大。头颅外形正常，眼球无外凸、

Dye,

rashandbleeding,noliverpalm,spidernevus,superficiallymphnodewithnopalpable.Thecranialshapenormal,

non

convex

eye,

内陷。眉毛无稀疏、脱落。双眼睑无下垂、浮肿，球结膜未见水肿，睑结膜无充血，巩膜无黄

Invagination.

Sparse

eyebrows,withoutshedding.Eyeliddroop,

noedema,conjunctivalnoedema,conjunctivalnocongestion,

no

yellow

sclera

染，

Dye,

两侧瞳孔等大等圆，

Bilateralpupilwaitforacirclegreatly,

直径

Diameter

3mm

3mm

，

,

对光反射灵敏。

Thelightreflexsensitivity.

双耳听力正常，

Binauralhearing,

外耳道通畅

Theexternalauditorycanal,

无异常分泌物，

Noabnormalsecretions,

乳突无压痛。鼻外形正常无异常分泌物，副鼻窦无压痛。口唇无紫绀口周无疱疹，口腔粘

Mastoidnotenderness.

Noseis

normal,no

abnormal

secretions,paranasalsinuswithouttenderness.Nolipscyanosis,mouthweekswithoutbleb,buccaladhesive

膜无溃疡牙龈无红肿，伸舌居中，咽部无明显充血，扁桃体不大。颈无抵抗颈静脉无怒张，

Filmwithoutulcers,

gingivalswelling

without,tongueisnoobvioushyperemia,

pharynx,tonsilisnot.

Neckno

resistance,nojugularveinengorgement,

肝

Liver

-

-

颈静脉回流征阴性

Jugularvenousrefluxsignnegative

,

,

气管居中甲状腺未触及肿大。胸廓对称无畸形，右侧呼吸动度正常，

Tracheae,nopalpablethyroid.Symmetricnonthoracicdeformity,ontherightsideofthenormalrespiratorymotion,

右侧语颤正常，

Therightlanguagefibrillationtonormal,

无胸膜摩擦感。

Nosenseofpleuralfriction.

双肺叩清音

Doublelungpercussionsound,

双肺呼吸音清晰

Doublelungbreathesphonicclarity

,

,

无干湿性啰音，

No

dryandwet

rales,

未闻及胸膜摩擦

Nopleuralfriction

音。

Sound.

心前区无隆起，

Freezoneupliftbeforetheheart,

无异常搏动

Noabnormalpulse,

心尖搏动点未见，

Apexbeatno,

触无震颤

Touchno

tremor,

心界不大

Heartgroupisnotbig,

心率

Heartrate

74

74

次

Time

/

/

分，

Divided,

律齐

Thelawisneat,

心音低钝各瓣膜听诊区未闻及病理性杂音，未闻及心包摩擦音。

Heartsoundsislowblunt,areaofeachvalveauscultationwithoutpathologicalmurmur,nopericardialfrictionsound.

专科检查：颈椎曲度变直，颈部肌肉僵硬，颈椎活动轻度受限，颈

Specializedexamination:

cervicalcurvature

becomesstraight,stiffneckmuscles,andcervicalspineslightlyrestricted,neck

4-

4-

颈

Neck

6

6

棘间压痛（

Interspinoustenderness(

+

+

）

)

，

,

颈

Neck

3-

3-

颈

Neck

6

6

棘旁两侧压痛（

Paraspinaltenderness(bothsides

+

+

）

)

，叩击痛（

,

percussionpain(

-

-

）

)

，双侧椎间孔挤压试验（

,

bilateralintervertebralforamenextrusiontest(

-

-

）

)

，叩顶试验（

Knocktest(top,

-

-

）

)

，臂丛牵

Brachialplexustraction,

拉试验左侧（

Theleft(tensiletest

+

+

）

)

、右侧（

,

(ontheright

side

+

+

）

)

，旋颈试验（±）

,

neckrotationtest

(±)

，双上肢肌力正常，肱二、肱三肌腱反射正常，双

Normal,

doubleupperlimbs

strengthof

two,three,tricepstendonreflexisnormal,double

侧霍夫曼征（

Hoffmansyndrome(side

-

-

）

)

，余病理反射未引出。

No

morethan,pathology

reflex.