Kien asked in 健康疾病與處置傳染病 · 1 decade ago

醫護 醫囑翻譯

ADMISSION NOTE

Present Illness

Pul TB.

anti-TB drug

suffered cough

He was snet to a local clinic and was then transferred to our hospital

for further evaluation and management.

Throughout the whole course of the present illnes there was no fever

or chills, and no cyanosis sign Tachycardia and nausea were noted

This time he was admitted from OPD to medical ward

herbal medicine

steroids

NIDDM

General Appearance: acutely ill-looking

Development: MD

Nourishment: MN

Mentality: alert

Skin: ecchymosis on extremities

Head and its Organs: intact

Conjunctiva: no anemic

Sclera: no icteric

Thyroid: not palpable

Neck: soft

Lymph Nodes: no palpable

Chest: symmetrical and full expansion

Heart: tachycardia with regular heart beat, no murmur

Lungs: wheezing sound in both lungs

Abdomen: soft and flat, no tenderness of rebounding pain.

Liver: not palpable

Spleen: not palpable

Extremities: no edema

Reflexes: no pathological reflex

Impression

Bronchial asthma

NIDDM

Pul TB

Cushing syndrome

plans

Bronchodilator drugs use

Blood sugar contotrl c(在C上面有一條線) OHA drugs use

Steroid drugs use

1 Answer

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  • 1 decade ago
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    ADMISSION NOTE入院紀錄

    Present Illness 現在疾病

    Pul TB.肺結核

    anti-TB drug有抗肺結核藥物使用

    suffered cough會有咳嗽的現象

    He was snet to a local clinic and was then transferred to our hospital

    for further evaluation and management.病人先至外面醫院就診轉而到我們醫院治療(sent to你有打錯字)

    Throughout the whole course of the present illnes there was no fever

    or chills, and no cyanosis sign Tachycardia and nausea were noted

    此次病況並無發燒.寒顫.發紺.呼吸過速.噁心等之症狀

    This time he was admitted from OPD to medical ward

    此次是由門診入病房

    herbal medicine 服用中藥

    steroids類固醇

    NIDDM非胰島素依存型糖尿病(就是成人型ㄉ糖尿病)

    General Appearance: acutely ill-looking 病人從外觀看來急性病態倦容

    Development: MD 發育狀況良好

    Nourishment: MN 營養狀況

    Mentality: alert '精神狀態:保持警覺

    Skin: ecchymosis on extremities四肢有瘀斑

    Head and its Organs: intact 頭部和其他組織未受損傷

    Conjunctiva: no anemic 結膜無貧血徵象

    Sclera: no icteric 鞏膜無黃疸徵象

    Thyroid: not palpable 甲狀腺無腫大

    Neck: soft 頸部柔軟

    Lymph Nodes: no palpable 淋巴腺無腫大

    Chest: symmetrical and full expansion胸部有對稱性的擴張

    Heart: tachycardia with regular heart beat, no murmur

    心臟:心跳有過速並有規則性的跳動,無心雜音

    Lungs: wheezing sound in both lungs

    肺部呼吸音:兩側呼吸音有喘鳴音

    Abdomen: soft and flat, no tenderness of rebounding pain.

    腹部:軟而平坦,無反彈痛

    Liver: not palpable 肝臟無摸到其他硬塊

    Spleen: not palpable脾臟無摸到其他硬塊

    Extremities: no edema 四肢無水腫

    Reflexes: no pathological reflex反射:無病理性的反射

    Impression 診斷

    Bronchial asthma 支氣管氣喘

    NIDDM非胰島素依存型糖尿病(就是成人型ㄉ糖尿病)

    Pul TB肺結核

    Cushing syndrome庫欣氏症候群

    plans 治療計畫

    Bronchodilator drugs use使用支氣管擴張劑

    Blood sugar contotrl c(在C上面有一條線) OHA drugs use

    血糖控制並且使用口服降血糖藥物

    Steroid drugs use類固醇藥物使用

    Source(s): 所學
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