Clinical genres

TTO form


General practitioner


Type 1 diabetes



Source Text in English
This is a 39 year old gentleman of Spanish origin who speaks minimal English and is in a same gender relationship. He is a Type I diabetic for 11 years with poor compliance to insulin, admitted with plantar abscess and has had amputation to 4 toes in his left foot. He was seen by respiratory team with increased SOB, raised CRP with mild lymphopenia. Raised ALP and GGT. CT chest shows bilateral upper lobe confluent airspace shadowing. Cardiomegaly and bilateral effusion. ?Atypical pneumonia ?fungal. He was treated with iv taz, septrin and clarithromycin. CTPA: no PE.
Target Text in Spanish
Varón de 39 años de origen español que apenas habla inglés y mantiene una relación homosexual. Padece diabetes de tipo 1 desde hace 11 años con baja adhesión terapéutica a la insulina. Ingresado con absceso plantar. Amputación de 4 dedos del pie izquierdo. Examinado por el servicio de neumología con aumento de disnea, proteína C-reactiva elevada y linfopenia leve. FA y γ-GT elevadas. La TC de tórax muestra sombreado alveolar confluyente bilateral en los lóbulos superiores. Cardiomegalia y derrame pleural bilateral. ?Neumonía atípica ?fúngica. Se le administró piperacilina-tazobactam i.v., trimetoprim-sulfametoxazol y claritromicina. Angiografía pulmonar por TC: sin EP.

Concise style

The clinical history summary in a discharge letter is a section characterised by a direct, objective and plain style. Brief and clear sentences have been used in both the original text and the translation. This helps summarise the patient’s current history, physical examination and complementary tests.

Acronyms and abbreviations

In communications among specialists it’s common to find an abundant use of acronyms and abbreviations which aren’t developed on their first occurrence. Although abbreviating repetitive terms enhances the reading flow, the translator must intervene to avoid abusive use of these mechanisms and seek the balance between fluency and transparency.

Drug names

The doctor who writes the clinical history often mixes the names of active ingredients and brands. Here, the author has used an abbreviated active ingredient name (taz), a brand name (Septrin) and an an unabbreviated active ingredient name (clarithromycin). Criteria have been unified in the translation.

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