Anonymous
Anonymous asked in 健康其他:保健 · 2 decades ago

請教看懂醫學病例的人~這些是什麼意思?

Family History: Non-contributory

Physical Examination:

General Appearance: Consciousness: clear, no respiratory distress.

SKIN: Normal turgor, abnormal pigmentation, no yellowish discoloration.

HEAD: No deformity, no surgical scar.

EYES: No icteric sclera, no anemic conjunctiva, isocoric pupils with prompt light reflex.

ENT: No otorrhea, no rhinorrhea, no hearing impairment.

NECK: Supple, no jugular vein engorgement, no palpable mass, no lymphadenopathy.

CHEST: Symmetrical expansion, Breathing sounds: clear, no wheezing, no rales.

HEART: Regular heart beats, no murmur.

ABDOMEN: Inspection: flat.

Auscultation: normoactive bowel sounds

Palpation: soft, no tenderness.

Percussion: no shifting dullness.

BACK&SPINE: Straight, no CV angle knocking tenderness.

EXTREMITIES: Full range of motion, no limited ROM of four limbs, no cyanosis, No clubbing fingers, no pitting edema, no palmar erythema.

DIGITAL EXAMINATION: Digital rectal examination: Loose anal sphincter, External hemorrhoid at anterior portion and left lateral portion of anus.

Prostate: smooth firm.

Anoscopy: internal hemorrhoid.

TENTATIVE DIAGNOSIS: 1.R/O Colon lesion.

2. Mixed hemorrhoid.

3. BPH

PLAN TO DO: 1.On admission routine.

2. IV fluid supplement

3. Colon preparation

4. Arrange colonoscopy.

Update:

那他都在評估哪些生理問題?

1 Answer

Rating
  • 2 decades ago
    Favorite Answer

    蚊子寶貝,前面那一大段只是基本的生理評估,所以我只幫你翻譯這一段,因為打一大堆其實沒太大意義,但是手好酸!

    TENTATIVE DIAGNOSIS: 1.R/O Colon lesion。疑似大腸機能障礙

    2. Mixed hemorrhoid.混和性痔瘡

    3. BPH 攝護腺肥大

    PLAN TO DO:治療計畫

    1.On admission routine.入院常規

    2. IV fluid supplement給點滴支持

    3. Colon preparation腸道準備

    4. Arrange colonoscopy安排大腸鏡檢查

    請問是你的家人住院嗎?祝他早日康復,平安

    Source(s): 自己
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