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急*入院記錄要英翻中

一般資料(General Data):

職業:其他建築師、工程師及有關專業

種族:台灣

婚姻:married

旅遊史:nil

職業病史:nil

主訴(Chief Complaint):

bed sore for helf year

現在病症(Present Illness):

A 33 year old man had a past history of spinal cord injury and L3 compression fracture for 15 qears associated with urinary urge incontinence and right drop foot. There is little limitation of his daily activity. He was admitted this time due to right gluteal pressure ulcer for half year. He had been treated in our OPD with duoDERM and intrasite. There was poor granulation formation and poor healing inspite of conserrative management. Therefore, he was admitted to our ward for further surgical management

過去病史(Past History):

82 Compression fracture,L3 s/p internal fixation, L2-4 and posterolateral fusion

94-05 Failed back spine syndrome

Tethered cord syndrome of L3 and L4

Intraspinal cyst of L2-L5 with cauda equine syndrome s/p operation

94-10 Bilateral globus pallid lesion

95-11 Urinary tract infection with Pseudomonas aeruginosa

96-05 Fracture over right clavicle

Hepatitis B

個人病史(Personal History):

Habbits喝酒:yes, quit for 7-8 years

Betelnut檳榔:no

Cigarette抽菸:pack per 3 days for about 20 years

Allergy:

Drug allergy藥物過敏:no knowning allergy

Food allergy食物過敏:no knowning allergy

Current medication:no

家族史(Family History):

Mother:diabetes

3 Answers

Rating
  • 1 decade ago
    Favorite Answer

    一般資料 (一般的資料):

    職業:其他建築師、工程師及有關專業

    種族:台灣

    婚姻:和

    旅遊史:無

    職業病史:無

    主訴 (主要的抱怨):

    床疼痛的為 helf 年

    現在病症 (禮物疾病):

    A 33 年老男人為與尿的呼籲失禁和正確的下降腳有關的 15 qears 有了脊髓受傷和 L3 壓縮破碎的過去歷史。 有他的每日活動的很少限制。 由於正確的臀壓力潰瘍,他這次被承認半年。 他在我們的 OPD 中被 duoDERM 和 intrasite 接受治療。 有貧窮的使成粒狀形成和 conserrative 管理的貧窮的治癒 inspite 。 因此,他為進一步的外科 m 被我們的病房承認

    過去病史: (越過歷史)

    82 壓縮破碎,L3 s/p 內在的定置、 L2-4 而且後外側的融合物

    94-05 失敗了後面的脊椎併發症狀

    鍊栓了 L3 和 L4 的繩索併發症狀

    L2 的 Intraspinal 包囊-L5 用 cauda 馬併發症狀 s/p 手術

    94-10個雙邊的 globus 蒼白的損害

    95-11個尿道發炎用假單細胞細菌 aeruginosa

    96-05 破碎結束正確的鎖骨

    B型肝炎

    個人病史 (個人的歷史):

    Habbits 喝酒:是的,離開 7-8 年

    檳榔檳榔:沒有

    香煙抽菸:每 3 天包裝大約 20 年之久

    過敏症:

    藥物過敏症藥物過敏:沒有已知的過敏症

    食物過敏症食物過敏:沒有已知的過敏症

    現在的藥物治療:沒有

    家族史 (家庭歷史):

    母親:糖尿病

    Source(s): 譯言堂網址:http://www.mytrans.com.tw/newmytrans/
  • 1 decade ago

    一般資料(General Data):

    職業:其他建築師、工程師及有關專業

    種族:台灣

    婚姻:married(已婚)

    旅遊史:nil(無)

    職業病史:nil(無)

    主訴(Chief Complaint):

    bed sore for helf year(長達半年的疼痛或痠痛)

    現在病症(Present Illness):

    A 33 year old man had a past history of spinal cord injury and L3 compression fracture for 15 years associated with urinary urge incontinence and right drop foot.

    一個33歲的人的病歷:脊椎有曾經有受傷過的經驗,而且在第三腰椎的第方有壓迫到並且(好像有)斷裂過,而且他的泌尿系統的功能不怎麼好,因為他有大小便失禁,到目前為止已有15年了。

    There is little limitation of his daily activity.

    這使他的日常生活作息有點小小的不方便(受到限制)!

    He was admitted this time due to right gluteal pressure ulcer for half year.

    他知道自己在這些病狀的期間,右邊的腎臟受到壓迫而潰瘍已有半年了。

    He had been treated in our OPD with duoDERM and intrasite.

    他過去一直服用我的藥物(OPD)還有濃縮的duoDERM.

    There was poor granulation formation and poor healing in spite of conservative management.

    之前有做過型式粗糙的療效及治療即使那些方法還滿老舊的。

    Therefore, he was admitted to our ward for further surgical management.

    因此,他認為我們的看護會有更深一層精確的管理。

    過去病史(Past History):

    82 Compression fracture,L3 s/p internal fixation, L2-4 and poster lateral fusion.

    在82年時曾經受到擠壓斷裂,但在第三腰椎的內部已固定好了。第二到第四腰椎的側面聯合。

    94-05 Failed back spine syndrome

    94年5月,背部衰退,導致脊椎併發症

    Tethered cord syndrome of L3 and L4

    脊椎併發的範圍在第三腰椎到第四腰椎

    Intraspinal cyst of L2-L5 with cauda equine syndrome s/p operation

    在第二腰椎到第五腰椎尾部有開過脊髓馬尾的手術

    94-10 bilateral globus pallid lesion

    94年10月,兩邊的眼球受損

    95-11 Urinary tract infection with Pseudomonas aeruginosa

    95年11月,泌尿道感染綠膿桿菌

    96-05 Fracture over right clavicle

    96年05月,右鎖骨斷裂

    Hepatitis B

    個人病史(Personal History):

    Habbits喝酒:yes, quit for 7-8 years

    之前有喝,但是戒掉了,戒掉有7~8年的時間了。

    Betelnut檳榔:no(沒有)

    Cigarette抽菸:pack per 3 days for about 20 years

    有20年的時間都是每天3包煙

    Allergy:

    Drug allergy藥物過敏:no knowning allergy

    不知道有沒有藥物過敏

    Food allergy食物過敏:no knowning allergy

    不知道有沒有食物過敏

    Current medication:no

    目前服用的藥物:沒有

    家族史(Family History):

    Mother:Diabetes

    母親:糖尿病

    Source(s): 自己是讀護理的
  • 1 decade ago

    你參考看看吧! 我盡力ㄌ! 希望能幫到你~~

    一般資料(General Data):

    職業:其他建築師、工程師及有關專業

    種族:台灣

    婚姻:married

    旅遊史:nil

    職業病史:nil

    主訴(Chief Complaint):

    bed sore for helf year

    現在病症(Present Illness):

    一個三十三歲的男子過去曾經有過脊椎損傷且因第三腰椎壓迫性骨折導致尿失禁長達十五年並且右跛腳。A 33 year old man had a past history of spinal cord injury and L3 compression fracture for 15 qears associated with urinary urge incontinence and right drop foot.

    這使得他的日常活動受到些限制。There is little limitation of his daily activity.

    此時他右臀有一潰瘍已達半年之久。He was admitted this time due to right gluteal pressure ulcer for half year.

    他來過門診使用人工皮及傷口敷藥治療。He had been treated in our OPD with duoDERM and intrasite.

    傷口上有些較差的粒狀物形成且傳統的治療方式有限。There was poor granulation formation and poor healing inspite of conserrative management.

    因此他將進入我們病房進行外科治療。Therefore, he was admitted to our ward for further surgical management

    過去病史(Past History):

    民82年 壓迫性骨折,第三腰椎內部固定,第二~四腰椎後外側融合。(82 Compression fracture,L3 s/p internal fixation, L2-4 and posterolateral fusion)

    民94-5第三及四腰椎引起的脊髓牽扯症候群,L2~L5脊椎外側囊腫致馬尾脊椎症狀開刀。(94-05 Failed back spine syndrome

    Tethered cord syndrome of L3 and L4, Intraspinal cyst of L2-L5 with cauda equine syndrome s/p operation)

    民94-10雙側蒼白球損傷。(94-10 Bilateral globus pallid lesion)

    民95-11因綠膿桿菌引發尿道感染。(95-11 Urinary tract infection with Pseudomonas aeruginosa)

    民96-05右鎖骨骨折。(96-05 Fracture over right clavicle)

    B型肝炎(Hepatitis B)

    個人病史(Personal History):

    Habbits喝酒:yes, quit for 7-8 years曾經有,已戒了7,8年

    Betelnut檳榔:no無

    Cigarette抽菸:pack per 3 days for about 20 years三天一包菸持續長約二十年

    Allergy:

    Drug allergy藥物過敏:no knowning allergy無任何過敏

    Food allergy食物過敏:no knowning allergy無任何過敏

    Current medication近期服用藥物:no無

    家族史(Family History):

    Mother母親 :diabetes 糖尿病

    2007-12-21 01:49:37 補充:

    漏了一句

    主訴(Chief Complaint):臥床半年(bed sore for helf year)

    Source(s): 自己
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