Anonymous
Anonymous asked in 健康其他:保健 · 1 decade ago

請教看懂醫學病例的人~這些是什麼意思?

Chief Complaint: Chang in bowel habit for days.

Present Illness:

This 73-year-old man had the history of BPH. He experienced urine retention about two weeks ago. He went to GU OPD where foley was inserted. CMG at GU OPD showed detrusor areflexia. According to him, Change in bowel habit happened during the same period. The frequency of stool passage was increased and abdominal dullness sometimes developed. He noted his body weight loss about 7kg(63kg-56㎏). General weakness was also noted. He visited our OPD on November23, 2005. Further evaluation was suggested. Therefore, he was admitted on November24, 2005.

Throughout his whole course of present illness, he had a change in bowel habit and body weight loss. He had no symptom of bloody stool, tenesmus, or decreased caliber of stool.

Past History:

1.BPH with medication (TRBx on June21,2005: nodular hyperplasia, bilateral)

2.Denied DM, hypertention, COPD, or pulmonary TB

Personal History:

1.Denied allergic history of drug or food.

2.Denied habit of smoking or alcohol drinking.

1 Answer

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  • 1 decade ago
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    Chief Complaint: Chang in bowel habit for days.主訴:這幾天大變型態改變

    Present Illness:

    This 73-year-old man had the history of BPH. 這個73歲的男人有攝護腺肥大的病史He experienced urine retention about two weeks ago. 他兩星期前開始有尿儲留.He went to GU OPD where foley was inserted. 他到泌尿科門診放入導尿管CMG at GU OPD showed detrusor areflexia.尿路動力學發現膀胱逼尿肌無反射 According to him, Change in bowel habit happened during the same period.根據他說的這段期間大便習慣改變 The frequency of stool passage was increased and abdominal dullness sometimes developed. 解便頻率增加且有腹脹感He noted his body weight loss about 7kg(63kg-56㎏).體重減少7公斤 General weakness was also noted. 全身感到虛弱He visited our OPD on November23, 2005. Further evaluation was suggested. Therefore, he was admitted on November24, 2005. 11/23來看門診進衣部評估後建議他住院11/24住院

    Throughout his whole course of present illness, he had a change in bowel habit and body weight loss. He had no symptom of bloody stool, tenesmus, or decreased caliber of stool. 整個疾病過程為大便習慣改變體重減少,沒有解血便,裏急後重感或糞便變小條.

    Past History: 過去病史

    1.BPH with medication (TRBx on June21,2005: nodular hyperplasia, bilateral) 有攝護腺肥大病史藥物治療

    2.Denied DM, hypertention, COPD, or pulmonary TB 沒有糖尿病、高血壓、慢性阻塞性肺病、肺炎或肺結核。

    Personal History:個人病史

    1.Denied allergic history of drug or food.對食物藥物沒有過敏史

    2.Denied habit of smoking or alcohol drinking. 沒有抽菸喝酒的習慣

    2005-11-28 00:08:21 補充:

    謝謝樓上大大的補充!

    感謝哩

    Source(s): 自己
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