Kellin asked in 社會與文化語言 · 1 decade ago

可以幫我翻譯Admission Note嗎? 急

(Chief Complaint )

首要主訴

Tarry stool passage for days.

(Present Illness)

According to the patient’s previous medical record and patient’s family,he has had history of Type 2 DM,HCVD,and COPD with regular medication.Hehas had symptoms of intermittent etigastric pain and dysphagia for months and ever diagnosed of gastric ulcer and gastric adenocarcinoma in cardiac region in tuis February.His family refused operation due to pood cardiopulmonary condition .This time he suffered from tarry stool passage for days.Thus he was brought to our MER where GI bleeding was impressed ,and he was admitted for further evaluation and management.

<Review of system>

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

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

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

>>GI:hausea(-)vomiting(-),poor apptite(-),tarry stool(+),abdominal pain(-),abdominal dissension(+),diarrhea(-),constipation(-)

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

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

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

(Past History)

History of systemic disease:Type 2 DM.HCVD and COPD,stomach ca

History of major operation:Denied

(Personal History)

Race:外省

Habit of alcoholic beverage drinking:Denied

Allergy history to drugs or food : Denied

History of occupation:Veteran

History of travtling:Nil

Carrent mediaction:(Family History) Family History:non-contributory.

(Phvsical Examination)

Vital sign:BT:36.3°C,PR:104/min,RR:18/min,BP:144/64mmHg

Body heught:156cm, Body weight:75kg(臥床)

General appearance:alerthness with ill-looking

2 Answers

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  • 1 decade ago
    Favorite Answer

    (行政投訴)

    焦油狀廢液的糞便通過幾天。 (目前的疾病)根據病人的以往的醫療記錄及病人的家庭,他曾經的歷史, 2型糖尿病, hcvd ,慢性阻塞性肺疾病與定期medication.hehas曾出現間歇性etigastric疼痛和吞嚥困難的幾個月和以往任何時候都診斷為胃潰瘍和胃腺癌在心臟地區在tuis february.his家屬拒絕的運作,由於pood心肺條件。這一次,他並遭受焦油狀廢液的糞便通過為days.thus ,他被帶到我們的匯率情況下消化道出血留下了深刻的印象,他承認,作進一步的評估和管理。

    &gt; &gt;憲法:疲勞( -) ,一般的弊病( - ),體重減輕(- ) ,冷出汗( -) ,發燒( - ),冷(- )

    &gt; &gt; heent :頭痛( -) ,減值的視野( - ),鼻漏( - ) ,r o a l潰瘍( -) ,咽喉痛( -) ,眩暈( - ) ,流鼻血( - ) ,鼻s t uf f i n ess(-),減值聽證會( -) ,頭暈( - )

    &gt; &gt;心肺呼吸:胸部疼痛( -) ,索布( - ),咳嗽(- ) ,心悸( -) , or t h opena(-),咳血( - ) ,痰( -)

    &gt; &gt;地理標示: hausea ( -) ,嘔吐( - ),窮人ap ptite(- ) ,焦油狀廢液的糞便( +) ,腹痛( -) ,腹部糾紛(+ ),腹瀉( - ),便秘( - )

    &gt; &gt;顧:頻率( -)的緊迫性( - ),排尿困難(- ) ,夜尿( -) ,漢克疼痛(- )

    &gt; &gt;神經:麻木( -)感官d isturb ance( - ),不穩定的步態(- ) ,嗜睡( -) ,不清的講話( - )

    &gt; &gt;皮膚和肢體:皮疹( -) ,瘀血( - ), p e techiae(- ) ,潰瘍( -) ,有限的R OM ( -),下肢凹陷性水腫(- ) ,p r ee s u re喉嚨痛(-)

    (過去的歷史)

    歷史的全身性疾病: 2型dm.hcvd和慢性阻塞性肺疾病,胃鈣

    歷史上的重大行動:否認

    (個人史)

    種族:外省

    的習慣,酒精飲料飲用:否認

    過敏的歷史,以藥物或食物:否認

    歷史的職業:退伍軍人

    歷史travtling :無

    carrent mediaction : (家族史)家族病史:非供款。

    ( phvsical考試)

    生命體徵:英國電信: 36.3 ° C時,公關: 104/min ,其RR : 18/min ,血壓: 144/64mmhg

    機構heught : 156厘米,體重: 75公斤(臥床)

    一般外觀: alerthness與虐待展望

  • 1 decade ago

    很多單字都打錯喔

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