益嘉 asked in 社會與文化語言 · 1 decade ago

醫療英文翻譯!很急!20點!

Denied allergy history

Alcohol(-)

Smoking(-)

Family History

Not contributory

Review of System

Head:

Headache(-)

Dizziness(-)

Vertigo(-) Traumatic injury(-)

Epilepsy(-)

Neck:

Stiffnss(-):

Muscular rigidity(-)

Lymphadenopathy(-)

Goiter(-)

Resp Sys:

Chest pain(-)

Chest tightness(-)

Cough(-)

Sputum(-)

Hemoptysis(-)

Dyspnea(-)

Wheezing(-)

P.N.D(-)

Cold sweating(-)

CV:

Orthopnea(-)

Palpitation(-)

Tachypnea(-)

Bradypnea(-)

GI:

Dysphagia(-)

Anorexia(-)

Pyrosis(-)

Abdominal pain(-)

Nausea(-)

Vomiting(-)

Diarrhea(-)

Constipation(-)

Eructation(-)

Melana(-)

Hematemesis(-) Hemorrhoid(-)

Tenesmus(-)

Urinary:

Dysuria(-)

Stranguria(-)

Polyuria(-)

Hematuria(-)

Incotinence(-)

C-V angle paun(-)

Hernia(-)

Nocturia(-)

Physical Examination

T:36.6/℃ P:97/min R:4/min BT:119/87/mmHg

General:

Consciousness:clear,E4V5M6

Not edematous

No dehydration

Mild jaundice

HEENT:

Sclera mild icteric

Conjunctiva not pale

Normal tongue appearance

Nack supple and freely movable,no JVE

Chest:

Symmetric expansion

Bilateral clear breathing sound without wheezing

RHB with murmur II/VI

Abdomen:

Soft and flat

No palpable liver and spleen

Active bowel sound

No abdomal pain

Extremities:

Freely movable and pitting edema(++)

Cranial Nerve

CN I-VF:intact

CN II-pupil size:3/3 light reflex:+/+

CN III,IV,VI-EOM:full

CN V-corneal reflex:+/+

CN VII-facial palsy:+/-

CN VIII-nystagmus

CN IX,X-gag reflex:+/-

Swallowing to water:mild dysarthria

CN XI-turning head (SCM)(+)intact

CN XII-tongue deviation(+)

Muscle power

Deep tendon reflex

Impression

1.Sever mitral valve regurgitation

2.Atrial fibrillation

3.Congestive heart failure

Plan

1.Arrange CATH tomorrow

2.Consult CVS doctor for evaluation the possibility of surger

3.Arrange 2D echo and pre-CATH survey

1 Answer

Rating
  • jingh
    Lv 5
    1 decade ago
    Favorite Answer

    前面一大堆ㄉ檢查

    是所謂身體檢查ㄉ結果

    從個人病史(有無過敏.喝酒.抽菸)

    家族史.到身體各系統(頭.頸.呼吸.心血管.腸胃.泌尿)

    (+)表示有問題(-)無異常

    再來就是生理檢查.外觀評估.四肢反射

    重要ㄉ是 Impression&Plan

    這位病人ㄉ診斷如下

    1二尖瓣閉鎖不全

    2心房震顫

    3鬱血性心衰竭

    處置有安排2D心臟超音波及照會心臟外科

    Source(s): 醫療人員背景
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