醫學翻譯高手請進~幫忙我~急。感恩

家族史 :

Atopy history : (+)his father had allergic rhinitis

系統整理 :

Marked=Postive

Eyes : blurred vision , discharge , redness , other : exophthalmos , double vision , pain , strabismus .

ENT : epistaxis , ** rhinorrhea , obstruction , pain , mass hearing impairment , otorrhea , otalgia others :

Lung : * cough , dyspnea , wheezing , chest pain , others :

CVS : palpitation , orthopnea , exercise intolerance prolonged feeding , cyanosis , syncope , others :

GI : * vomit , hematemesis , mass , * diarrhea , *** distension constipation , bloody stool , pain swallowing disturbance , others :

GU : dysuria , discharge , bleeding mass , others :

Skeletal system : deformity , swelling , pain others :

CNS : mental retardation , seizure , developmental delay motor weakness , sensory impairment , microcephaly macrocephaly , learning disorder , headache behavioral disorder , fever , others :

Endocrine : sexual precocity , growth retardation obesity , emaciation , polyuria , polydipsia , others :

Skin : depigmention , jaundice , bleeding tendency hyperpigmentation , others :

理學檢查 :

Consciousness : alert

Respiration : sommth

Neck : supple LAP : not enlarged

Conj : not pale

Sclerae :not icteric

Throat : injected , no ulcers

Tonsil : not enlarged

Chest : symmetrical expansion , no retraction

BS : bilateral coarse , no rales

HS : RHB no murmur

Abdomen : tense and distension (++) , tympanic on percussion muscle guarding (+) ( irritable crying when palpation )

Liver : impalpable

Spleen : impalpable

Bowel sound : hypoactive ( hyperactive on LLQ ? )

EXT : freely movable

Skin rash : not found

臨床診斷 :

Abdominal distension

Suspected paralytic ileus

Suspected infectious enterocolitis

Suspected potential sepsis

處理計畫 :

NPO and adequate IVF replacement

Empiric antibiotics with ampicillin , fortum and metronidazole

Arrange plain abdomen of left decubitus for r/o pneumoperitoneum

Arrange abdominal echo for intra-abdominal lesions

2 Answers

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  • 1 decade ago
    Favorite Answer

    病歷最好別偷懶, 自己看才會進步!

    家族史 :

    Atopy history : (+)his father had allergic rhinitis 他爸有過敏性關節炎

    系統整理 :

    Marked=Postive

    Eyes : blurred vision 視力模糊, discharge流淚 , redness紅眼 , other : exophthalmos(?) , double vision雙重視覺 , pain疼 , strabismus斜視 .

    ENT耳鼻喉 : epistaxis鼻出血 , ** rhinorrhea流鼻水 , obstruction鼻塞 , pain疼 , mass hearing impairment 重度聽力受損, otorrhea耳的發膿? , otalgia耳痛 others :

    Lung : * cough咳嗽 , dyspnea呼吸困難 , wheezing呼吸發出吹哨般聲響 , chest pain胸痛 , others :

    CVS : palpitation心悸 , orthopnea? , exercise intolerance prolonged feeding運動時血氧不足? , cyanosis臉色發青? , syncope暈厥 , others :

    GI : * vomit嘔吐 , hematemesis出血? , mass , * diarrhea腹瀉 , *** distension constipation某某阻塞導致便秘 , bloody stool血便 , pain swallowing disturbance吞嚥疼痛造成的功能障礙 , others :

    GU : dysuria惡尿?(不知是指排尿困難還是尿中有不好的因子?), discharge流液?尿失禁? , bleeding mass 重度出血?, others :

    Skeletal骨骼 system : deformity變形 , swelling腫脹 , pain疼 others :

    CNS中樞 : mental retardation心智遲鈍 , seizure癲癇 , developmental delay motor weakness惡化中的運動能力衰退? , sensory impairment感官(觸,溫度,疼痛等)受損 , microcephaly macrocephaly一邊大一邊小的畸型頭?, learning disorder學習障礙 , headache behavioral disorder頭痛導致的行為不當? , fever發燒 , others :

    Endocrine內分泌 : sexual precocity性早熟 , growth retardation obesity生長賀爾蒙導致的肥胖? , emaciation憔悴 , polyuria糖尿? , polydipsia? , others :

    Skin : depigmention除去色素沉澱(白子?) , jaundice黃疸 , bleeding tendency hyperpigmentation血色傾向於沉澱於皮膚? , others :

    理學檢查 :

    Consciousness意識 : alert危急

    Respiration呼吸 : sommth?

    Neck : supple LAP我猜是供氧器 : not enlarged

    Conj : not pale 不蒼白

    Sclerae :not icteric ?

    Throat : injected , no ulcers ?

    Tonsil扁桃腺 : not enlarged未發炎

    Chest : symmetrical expansion吸氣時對稱性擴張 , no retraction沒有肺塌陷

    BS : bilateral coarse兩肺呼吸聲音嘈雜 , no rales 無羅音

    HS : RHB no murmur ?

    Abdomen : tense緊繃 and distension腫大 (++) , tympanic on percussion muscle guarding (+)? ( irritable crying when palpation觸診會哀嚎 )

    Liver : impalpable摸不到

    Spleen : impalpable 摸不到

    Bowel sound腸聲 : hypoactive低度蠕動? ( hyperactive on LLQ ?在LLP時高度蠕動? )

    EXT難道是四肢? : freely movable可動的

    Skin rash皮疹 : not found未發現

    2006-10-01 22:38:25 補充:

    臨床診斷 :

    Abdominal distension 腹部腫脹

    Suspected paralytic ileus 懷疑有麻痺性腸阻塞

    Suspected infectious enterocolitis 懷疑有感染性腸炎

    Suspected potential sepsis懷疑有可能有膿毒症

    2006-10-01 22:38:56 補充:

    處理計畫 :

    NPO and adequate IVF replacement 使用不經口服的靜脈輸注

    Empiric antibiotics with ampicillin , fortum and metronidazole 經驗療法: 投與ampicillin, fortum and metronidazole三種藥物

    2006-10-01 22:39:09 補充:

    Arrange plain abdomen of left decubitus for r/o pneumoperitoneum我猜是做插管氣切?(保持呼吸)

    Arrange abdominal echo for intra-abdominal lesions 安排腹部超音波檢查

  • 5 years ago

    到下面的網址看看吧

    ▶▶http://qaz331.pixnet.net/blog

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