亂寫病歷

林萬哲

病歷的記載，首重精確；其次凡相干的事件，無論其為正性或負性，均不可疏漏。在用詞構句方面，一定要遵循文法的正則，才能將事體表達得清楚明白。不管使用何種語文記載，都不能含糊。
我從網路上蒐集了一些有瑕疵的英文病歷記載，有的由醫師信口口述，大都為修飾詞不當錯置，有的由其他醫事人員誤用醫學辭彙而造成。這些例句，稍予考究，就知道它錯得頗為離譜，所以會鬧笑話。從第1題到第19題乃由署名Rubin者所提供，他自Richard Lederer所著的Fractured English裡引用了多則醫師記錄。第20題到第28題則另有來源，可能是包括其他醫事人員的「傑作」，一時也查不清楚。前28題我在2001年整理脫稿，曾刊載於台大耳鼻喉科的《反射鏡》2001年秋刊。自第29題到第41題是我新近從網路ArcaMax Jokes(November 2006)上看到而剔除與第1題至第28題重複的部分；其原文晦澀難明，頗為費解，我請教了在美國的同學楊勝賢兄幫忙解讀，相信已揣摩到很接近原意的詮釋。惟從第38題至第41題，其文句詞與詞之間的關聯性很鬆散，勉強予以添加敘述，或許會與原意大相逕庭。我的立場是不越俎代庖，故只揭示原文，留待讀者之卓裁。
在此我一面將各句的原文敘出，一面將對它的修正意見附註於後。閱者同道，若有更佳高見，請不吝指正賜教。

1. By the time he was admitted, his rapid heart had stopped and he was feeling better.
這裡rapid heart如果stopped，病人還能活嗎？所以應改為：
By the time he was admitted, his tachycardia (rapid heart rate) had subsided and he was feeling better.

2. Patient has chest pain if she lies on her left side for over a year.
靠左側躺超過一年，怎能不胸痛？
For over one year, the patient feels chest pain when she lies on her left side.

3. The patient states there is a burning pain in his penis which goes to his feet.
病人penis到達feet(腳)，也未免太長了吧！揣其意，應是其痛放散(radiate)到腳才對。
The patient states there is a burning pain in his penis and the pain radiates to his feet.

4. On the second day the knee was better and on the third day it had completely disappeared.
翌日膝蓋改善，第三天則完全消失，這是甚麼話？他把症狀漏寫了吧。茲以pain為例：
On the second day knee pain got better and on the third day the pain had completely disappeared.

5. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.
丈夫說她昨夜very hot in bed，令人想入非非。這無非要表示她昨夜體溫高，發燒而已。
She has had no rigors or shaking chills, but her husband states she was rather febrile in bed last night.

6. The patient has been depressed ever since she began seeing me in 1983.
此句給人的印象是病人自從1983年開始看這位醫生就引發憂鬱而一直未癒。我們不禁要問：該醫生是不是長得三頭六臂，不然外觀一定有甚麼特別嚇人之處？實際上應是病人憂鬱之後才開始並一直看這位醫生才對。
The patient has been depressed since 1983. For that depression, she began to consult me.

7. I will be happy to go into her GI system. She seems ready and anxious.
進入她的消化道，醫師會happy(快樂)，這是甚麼道理？
I am going to perform endoscopic examination for her GI system. She seems to be ready, though anxious.

8. Patient was released to outpatient department without dressing.
別讓人誤以為without dressing是不穿衣服。這dressing不難看出是wound dressing吧，而wound dressing內的任何一字可不是能省的。
The patient was released to the outpatient department without wound dressing.

9. I have suggested that he loosen his pants before standing, and then, when he stands with the help of his wife, they should fall to the floor.
我想這句只是單純肯定、否定弄錯而已。
I have suggested that he tighten his pants before standing, and so, when he stands with the help of his wife, they should not fall to the floor.

10. Discharge status: Alive but without permission.
活著，還要許可？應是出院未經許可吧。
Discharge status: Alive, but leaves hospital without doctor’s permission.

11. The patient will need disposition; therefore Dr. Blank will dispose of him.
真希望病人需要的處置只是治療，而非把他處理(幹)掉。
The patient will need treatment; therefore Dr. Blank will treat for him.

12. Healthy-appearing, decrepit 69-year-old male, mentally alert but forgetful.
此處healthy-appearing與decrepit(衰弱)，互相矛盾，取其一即可。
Healthy-looking, 69-year-old man, mentally alert, but forgetful.

13. The patient refused an autopsy.
許諾autopsy可是百年後的事，因此別把biopsy錯成autopsy才好。
The patient refused a biopsy.

14. The patient has no past history of suicides.
病人過去若自殺成功，這次也不會來就醫了；所以suicides應是suicidal attempts。
The patient has no past history of suicidal attempts.

15. The patient expired on the floor uneventfully.
斷氣在地板上(或病房)，誰說uneventfully？將該字刪除即可。
The patient expired on the floor.

16. Patient has left his white blood cells at another hospital.
白血球留在其他醫院，也太吊詭了吧！不用說講的一定是檢查報告。
The patient has left his white blood cell count report at another hospital.

17. Patient was becoming more demented with urinary frequency.
更加癡呆，與頻尿何干？應該分別敘述。
The patient was becoming more demented. He also had urinary frequency.

18. The patient's past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
病人既往歷無啥特別(當然無需remarkably)，這次發病乃自三天(?)之前。只要分開敘述，應無問題；但3天增加40磅也太多了吧！這裡我想留待閱者之卓裁。或許非3天，而是3個月(或3星期)甚至3年也說不定。
The patient’s past medical history has been insignificant until the onset of present illness. This time there is a 40-pound weight gain in the past three months (or years).

19. The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.
修飾詞使用不當，惡化的應為肺水腫，而非性行為。
While having sex at home, the patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema, which gradually deteriorated in the emergency room.

20. Rectal exam revealed a normal size thyroid
檢查thyroid不需靠rectal examination甚明。
Physical examination revealed a normal-sized thyroid.

21. She stated that she had been constipated for most of her life until 1989 when she got a divorce.
這裡constipation與divorce應該沒有關聯，所以只好分別敘述。
She stated that she had been constipated for most of her life until 1989. In that year she got a divorce.

22. The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately.
此句pediatrician後面的修飾子句，很明顯是描述嬰兒。
The baby was delivered, the cord being clamped and cut. It breathed and cried immediately. Then the baby was handed to the pediatrician.

23. The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
此句who以下的子句，顯然在修飾father。
The patient lives at home with his mother, father, and a pet turtle. His father is currently enrolled in day care three times a week.

24. Both breasts are equal and reactive to light and accommodation.
把pupils寫成breasts也太菜了。
Both pupils are equal and reactive to light and accommodation.

25. She is numb from her toes down.
此處所說的from toes down，不知是甚麼部位？也許是from hip down吧。
She is numb from her hip down.

26. While in the emergency room, she was examined, X-rated and sent home.
自己造字，看似高明；奈有違「約定俗成」何？
When in the emergency room, she received physical and radiographic examinations. Then she was sent home.

27. Patient suffers from occasional, constant, infrequent headaches.
這裡又是constant，又是infrequent，顯然矛盾。
The patient suffers from occasional headaches.

28. Patient was alert and unresponsive.
又alert，又unresponsive，也太矛盾了吧。
The patient was alert and responsive.

29. The patient is tearful and crying constantly. She also appears to be depressed.
憂鬱而好哭，很有可能；但眼淚盈眶的描述，似無必要。所以這tearful顯然多餘，就免了罷。重新排列，成為：
The patient appears depressed and cries constantly.

30. Patient had waffles for breakfast and anorexia for lunch.
病人吃waffles(雞蛋餅)當早餐，以anorexia(食慾不振)為午餐。這是什麼話？若改為病人吃雞蛋餅當早餐，但午餐時間就變得食慾不振了。
The patient had waffles for breakfast but became anorexic at lunch time.

31. Between you and me, we ought to be able to get this lady pregnant.
你我守個默契不要透露給任何人，我們應能使這位女士懷孕。這不會讓人以為你們兩人要幹什麼歪事才怪。要保證不令人起疑，且讓人覺得你們醫術高明。 只得寫…我們有辦法治療這位女士的不孕症，而成：
Between you and me, we ought to be able to treat this lady's infertility.

32. The skin was moist and dry.
皮膚又濕又乾，合起來說一定不合理。一個辦法是刪掉其中一項，留下另外一項，變成：
The skin was moist. 或
The skin was dry.
另一個辦法是假定病人全身皮膚，有些地方濕，有些地方乾，而寫為：
The skin was moist in some areas but dry in other areas.

33. I saw your patient today, who is still under our car for physical therapy.
很顯然car是care之誤。所以改為：
Today I saw your patient, who is still under our care for physical therapy.

34. The lab test indicated abnormal lover function.
此公把liver誤植為lover，可以說有一點心不在焉。準此以改，就是：
The lab test indicated abnormal liver function.

35. Skin: somewhat pale but present.
皮膚蒼白已足表達，present刪除即可。變成：
Skin: somewhat pale.

36. Patient was seen in consultation by Dr. ____, who felt we should sit on the abdomen
and I agree.
這裡的sit on非常吊詭，不得已，代之以focus on。
The patient was seen in consultation by Dr.____, who felt we should focus on the abdomen and I agreed.

37. The pelvic exam will be done later on the floor.
雖說floor也可以當成病房(ward)使用，但如此描述，難免令人誤會為在地板上做內診檢查。為了清晰表達，假設檢查室在二樓，就可改為：
The pelvic exam will be done later in the examination room on the second floor.

38. The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
39. Large brown stool ambulating in the hall.
40. Patient has two teenage children, but no other abnormalities.
41. Patient was found in bed with her power mower.
這四題僅提出原文，請讀者自行琢磨。

以上舉例闡述，旨在希望能引起醫師同道們寫病歷時隨時注意，且巨細靡遺、面面俱到，而能收恰到好處的記述之效。