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*急*病歷翻譯!!非常感激^^

chief complaint

sudden onset of conscious change today

present lllness

The 84y/o male was a p’t of 1. HTN 2.cerebellum ICH with IVH and hydrocephalus, he was victim of severe dizzines today. He was sent to ER for help. The condition at ER, GCS was E3M5V2, pupil sized 2.0+/2.0+. A brain CT was performed to R/O brain lesion. The brain CT showed cerebellum ICH with IVH and hydrocephalus. He had the history of DM.HTN.old CVA with medical treatment and denied other chronic disease and drug allergy. He was admitted for further treatment.

2 Answers

Rating
  • 啟坤
    Lv 6
    2 decades ago
    Favorite Answer

    主訴:今天忽然意識改變.病史:這個84歲的男性, 過去病史有1)高血壓 2)小腦出血性中風合併腦室水腫及水腦, 今天感到非常頭暈, 便被送到急診就醫. 急診就醫時的情形, GCS是E3M5V2, 瞳孔大小雙側都是2.0+. 醫師便安排了腦部電腦斷層掃描來排除腦部的病變, 腦部電腦斷層結果發現小腦出血性中風, 並合併腦室水腫及水腦. 這個病人過去病史包括有糖尿病, 高血壓, 舊的中風, 並且都有在接受藥物治療, 他否認有其他的慢性病及過敏史. 於是他住院接受進一步的治療.

    Source(s): 自己-耳鼻喉科醫師
  • 2 decades ago

    主述

    今天突然覺得神志有些變化

    84歲的男性病人 1 高血壓(HTN)

    2.小腦顱內出血 與腦水腫, 今天感到非常暈眩。他至急診求診。急診評估, GCS (一種評估的評昏連指數的評定表)是E3M5V2, 2.0+/2.0+ 。頭部電腦斷層初步疑似有病灶。頭部電腦斷層顯示了後腦顱內出血與腦水腫。他有糖尿病高血壓中風的老毛病以藥物治療和並沒有其它慢性疾病和藥物過敏。他需要進一步治療。

    Source(s): 自己
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