阿于瑄 asked in 健康其他:保健 · 1 decade ago

有關醫囑翻譯,有關神經外科的~極需!!

主訴:(Chief Complaint)

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nasal bleeding & RN for days

現在病症:(Present Illness)

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This 60 year-old female patient had Hypertension under medication.She has experienced nasal bleeding & RN for days. She visited OPD of our division where she received left nasal biopsy and patho showed SINONASAL TERATOCARCINOSARCOMA. Head neck MRI: left nasal ethmoid intradural invasion. PET revealed Primary nasal cavity cancer with bilateral retropharyngeal lymph node metastases. He is admitted to our ward for further evaluation and treatment. Surgery has been arranged.

過去病史:(Past History)

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DM ( -)

HTN (+)

Renal disease ( -)

Heart disease ( -)

Drug allergy: NIL

個人病史:(Personal History)

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# Drug allergy: denied

# Smoking: denied

# Alcohol: denied

# Betel nuts chewing: denied

家族史:(Family History)

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no known familial hereditory disease

臨床臆斷:(Impression)

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1.SINONASAL TERATOCARCINOSARCOMA

處理計畫:(Plan)

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#. Well explained the risk of surgery and the possible complication to the patient and the family members

#. Pre-operation survey and arrange craniofascial resection

#. Symptomatic treatment if there was complaints.

1 Answer

Rating
  • 1 decade ago
    Favorite Answer

    這是住院病歷,不是醫囑

    簡單說明一下大意,不逐字翻譯了

    主訴:(Chief Complaint)

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    流鼻血/鼻涕數天

    現在病症:(Present Illness)

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    60歲的女性病人因流鼻血/鼻涕數天,到門診求診,接受了左鼻腫瘤的切片,結果是鼻惡性腫瘤(類似畸胎瘤,專門的中文翻譯找不到)。核磁共振顯示左側篩竇腫瘤且侵犯到硬腦膜。正子掃描顯示鼻腫瘤併兩側後咽淋巴轉移。住院預計接受手術治療。

    過去病史:(Past History)

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    有高血壓

    個人病史:(Personal History)

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    沒藥物過敏,沒使用菸酒檳榔

    家族史:(Family History)

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    無遺傳性疾病

    臨床臆斷:(Impression)

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    鼻惡性腫瘤 SINONASAL TERATOCARCINOSARCOMA

    處理計畫:(Plan)

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    *解釋手術風險及併發症

    *術前檢查並安排手術 (顱顏切開手術)

    *若有不適,先給予症狀治療

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