可否幫忙翻譯...謝謝...這是學校報告非真實案例
PHx:1. head injury Hx: nil
2. growth/development: within normal range
3. previous attack of seizure: had febrile convulsion Hx
4. family Hx of seizure: nil
5. Received HAV vaccination on yesterday. Antipyretic suppository use
at home just now.
過去病史:(Past History)
1.NKA
2.Denied any other systemic disease
3.family history: no contributory
4.G6PD deficiency :negative
個人病史:(Personal History)
Vaccination: as scheduled
No Bleeding tendency
系統整理:(Review of System)
Marked=Positive**
Eyes: blurred vision, discharge, redness, other:
exophthalmos, double vision, pain, strabismus
ENT: epistaxis, rhinorrhea, obstruction, pain, mass
hearing impairment, otorrhea, otalgia, others:
Neck:pain, limitation of movement, mass, others:
Lung:cough, dyspnea, wheezing, chest pain, others:
CVS:palpitation, orthopnea, exercise intolerance
prolonged feeding, cyanosis, syncope, others:
GI: vomit, hematemesis, mass, diarrhea, distension
constipation, bloody stool, tarry stool, pain
swallowing disturbance, others:
GU:dysuria, discharge, bleeding, mass, others:
skeletal system: deformity, swelling, pain others:
CNS: mental retradation, **seizure, developmental delay
motor weakness, sensory impairment, microcephaly
macrocephaly, learning disorder, headache
behavioral disorder,** fever, others:
Endocrine: sexual precocity, growth retardation
obesity, emaciation, polyuria, polydipsia, others:
Skin: depigmentation, jaudice, bleeding tendency hyperpigmentation, **skin warm
2 Answers
- singerLv 61 decade agoFavorite Answer
過去病史:
無頭部外傷病史。
生長發育:正常。
之前癲癇發作史:曾有熱性痙攣的病史。
無痙攣的家族史。
昨天剛施打 A型肝炎疫苗,並在家使用肛門塞劑退燒。
過去病史:
無過敏史。
否認有其他全身疾病。
家族疾病:不詳。
病患沒有葡萄糖六磷酸鹽脫氫酶缺乏症(又名蠶豆症)
個人病史:
疫苗接種:皆按照時間施打。
無出血傾向(如血友病)。
系統整理:
做記號**的為異常。
眼睛:無視力模糊、無分泌物、無紅眼睛、無凸眼、無
複視、無眼睛痛、無斜視
耳鼻喉:無流鼻血、無流鼻水、無鼻塞、無鼻痛、無鼻
腫塊、無聽力異常、無耳朵流膿、無耳痛
頸部:無脖子痛、無頸部活動受限、無頸部腫塊
肺部:無咳嗽、無呼吸困難、無喘鳴、無胸痛
心血管系統:無心悸、無端坐呼吸、無運動耐受力差、
無需延長餵食、無發紺、無暈厥
腸胃道:無嘔吐、無咳血、無腫塊、無腹瀉腹脹、無便
秘、無血便或柏油色便、無腹痛、無吞嚥困難
泌尿生殖系統:無解尿不適、無尿道分泌物、無血尿
、無腫塊
中樞神經系統:無智能障礙、有癲癇、無發展遲緩、無
肌肉無力、無感覺障礙、無畸形小頭、亦無巨頭
、無學習障礙、無頭痛、無行為異常、有發燒
內分泌:沒有性早熟、無生長遲緩、無肥胖亦無消瘦
、無多尿症、無多吃症
皮膚:無色素褪化、無黃疸、無出血傾向、無色素沈著
、皮膚溫暖
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