可以幫我翻譯Admission Note嗎? 急

(Chief Complaint)

General weakness and chills since last night.

(Present Illness)

According to the patient's and his family, he was a victim of hypertensive cardiovascular disease, coronary artery disease and type2 DM for years. He was found to have liver tumor and revieved radiofrequency treatment last month. edema of blilateral lower legs, mild shortness of breath developed last month and type 2 DM with DM nephropathy was impressed after hospitalization at our ward. He suffered from general weakness and chills since last night. There was rio fever. So he was sent to our ER for help. At ER, series examination was arranged, and elevated serum creatinine level was noted. CXR showed increased infilteation over left lung. Pneumonia was impressed. He was the admitted to our ward for further evaluation and management.

<Review of system>

>>Constitutional: fatigue (-), general malaise (+), weight loss (-), cold sweating (-), fever (-), chills (-)

>>HEENT: headache (-), impairment of hearing (-), dizziness (-), vertigo (-), epistaxis (-), nasal stuffiness (-), rhinorrhea (-), oral ulcer (-), sore throat (-)

>>Cardio-Respiratory: chest pain (-), SOB (+), cough (-), palpitation (-), orthopnea(+), hemoptysis (-), sputum (-)

>>GI:nausea (-), vomiting (-), poor appetite (-), tarry stool (-), abdominal pain (-), abdominal distension (-), diarrhea (-), constipation (-)

>>GU: frequency (-), urgency (-), dysuria (-), nocturia (-), hematuria (-), flank pain (-)

>>Endocrine: skin pigmentation (-), hirsutism (-), decreased libido (-)

>>Neurological: numbness (-), sensory disturbance (-), unstable gaits (-), lethargy (-), slurred speech (-)

>>Skin and Extremity: skin rash (-), ecchymosis (-), petechiae (-), ulcer (-), limited of ROM (-), lower leg pitting edema (+), pressure sore (-)

2 Answers

Rating
  • 1 decade ago
    Favorite Answer

    主訴

    從昨夜開始有全身無力及寒顫情形

    目前疾病

    根據病患及家屬陳述,病患患有高血壓性心血管疾病、冠狀動脈疾病、第二型糖尿病數年了

    He was found to have liver tumor and received radiofrequency treatment last month. 上個月被發現有肝腫瘤並接受了輻射電波治療

    而上個月開始有雙下肢水腫、呼吸短促情形,而第二型糖尿病及糖尿病腎病變情形在本病房住院期間明顯.

    昨晚他開始有全身無力及寒顫情形

    There was NO fever.(但)沒有發燒情形

    於是便被送至本院急診求助

    在急診已安排一系列檢驗,並發現血清肌甘酸指數上升

    CXR showed increased infiltration over left lung.胸部X光發現有左肺浸潤情形

    應是肺炎

    便住入本病房以進行進一步評估及處置

    系統回顧檢視

    全身體質狀況:無倦怠感, (+)有全身不適情形, 無體重喪失、冒冷汗、發燒、寒顫情形

    頭頸部檢查: 無頭痛、聽力缺損、頭昏、暈眩、鼻出血、鼻塞、流鼻涕、口腔潰瘍、喉嚨痛

    心肺系統: 無胸痛, 有呼吸短促, 無咳嗽,無心悸, 有端坐呼吸情形, 無咳血咳痰

    腸胃系統:無噁心、嘔吐、食慾變差、解黑便、腹痛腹漲、腹瀉便秘

    生殖泌尿系統: 無頻尿、急尿、排尿困難、夜尿、血尿、腰痛

    內分泌: 無皮膚著色、多毛或性慾減低情形

    神經系統: 無麻痺、感覺紊亂、步態不穩、昏睡倦怠、發音含糊情形

    皮膚及四肢: 無皮膚起疹、出血瘀斑瘀點、潰瘍、關節活動受限情形,下肢有壓陷性水腫,無壓瘡

    2008-03-19 12:38:35 補充:

    如有需要再給我聯繫方式!

    Source(s): 醫護背景+冒被移除危險.....寄給你吧!
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