映瀅 asked in 健康其他:保健 · 1 decade ago

請幫我校對病歷翻譯,想確定翻的對不對!?

ADMISSION NOTE

Chief Complaint:

Repeated vomiting for 2 days.

Diarrhea for 2 days.

Present Illness:

This 5 year-old girl suffered from diarrhea for 1 day. This stool is brown , watery (+1) , mucus (+1) , blood-tinged (-). The frequency of diarrhea is 3~4 time per day. Fever off and on was noted today. Besides , vomiting frequently was found since 2 days ago. The patient also complained of abdominal pain. According to the statement from the family , the patient presented poor appetite and poor activity recently. The patient was brought to our outpatient department today. Under the impression of acute gastroenteritis , the patient is admitted to our ward for further evaluation and treatment.

Past History:

1.Systemic disease:denied

2.G6PD def:negative

3.Drug or food allergy:denied

Family History:

Non-contributory

Physical Examination:

GA:ill-looking , general malaise

HEENT:injected pharynx and tonsil dry mucosa

Cheat&Lung:Symmetric expansion , clear breathing sound

Heart:RHB without murmur

Abdomen:soft and distend hyperactive bowel sound

no hepatosplenomegaly

Skin:fair skin turgor

Laboratory Date:pending

Diagnosis and problems:

Acute Gastroenteritis

Plan:

CBC/DC、CRP、Na、K、Cl、Glu、B/C、S/A、S/C、Hydratin、Digestants、Sent S/Rota

住院紀錄

主訴:

反覆嘔吐2天

腹瀉2天

現在病況:

這是一位5歲的小女孩,腹瀉第一天,糞便呈褐色、鬆軟(+1)、黏稠(+1)、血色(-)。腹瀉的頻率一天3~4次。今天沒有退燒又發燒。而且,2天前發現嘔吐頻繁。病人也訴說有腹痛情形。與家人陳述相符,目前病人胃口差,最近活動力差。病人為今天此部門的門診病人。臆斷為急性胃腸炎,病人願意住院進一步評斷與治療。

過去病史:

1.全身疾病:無

2.葡萄糖-六-磷酸鹽去氫酵素:陰性

3.藥物或食物過敏:無

家族病史:

身體檢查:

一般外貌:看起來不健康,大體上不舒服

頭眼耳鼻喉:咽頭注射,扁桃腺乾有黏膜

胸和肺:整齊擴張,呼吸聲清澈

心臟:心跳節律正常,無雜音

腹:柔軟、膨脹,腸活動過度有聲音,肝脾無腫大

皮膚:皮膚白皙腫脹

實驗日期:到痊癒為止

診斷和問題:

急性胃腸炎

治療計劃:

全血球計數/停止、C-反應蛋白質、鈉、鉀、氯化物、葡萄糖、B/C、糖與丙酮、S/C、氫氧化物、消化劑、送S/Rota

※有些不會翻 所以麻煩幫我翻 謝謝^^

Update:

S/Rota 是什麼??

1 Answer

Rating
  • 1 decade ago
    Favorite Answer

    住院紀錄

    主訴:

    反覆嘔吐2天

    腹瀉2天

    現在病況:

    這是一位5歲的小女孩,腹瀉第一天,糞便呈褐色、鬆軟(+1)、黏稠(+1)、血色(-)。腹瀉的頻率一天3~4次。發燒退又燒(斷斷續續)。 而且,2天前發現嘔吐頻繁。病人也訴說有腹痛情形。與家人陳述相符,目前病人胃口差,最近活動力差。病人因此來掛我的門診。臆斷為急性胃腸炎,病人入院做進一步評估與治療。

    過去病史:

    1.全身疾病:無

    2.葡萄糖-六-磷酸鹽去氫酵素:陰性

    3.藥物或食物過敏:無

    家族病史:

    身體檢查:

    一般外貌:全身不適

    頭眼耳鼻喉:咽頭注射,扁桃腺乾有黏膜,扁桃體粘膜

    胸和肺:整齊擴張(對稱擴大),呼吸聲清澈(明確呼吸聲)

    心臟:心跳節律正常,無雜音

    腹:柔軟、膨脹,腸活動過度有聲音(腸聲過度活躍),

    肝脾無腫大

    皮膚:皮膚白皙腫(硬)脹

    檢驗日期:到痊癒為止

    診斷和問題:

    急性胃腸炎

    治療計劃:

    完全血球計數/白血球指數、發炎指數、鈉、鉀、氯、葡萄糖(血糖)、血液培養、糞便檢查S/R、糞便培養、氫氧化物、消化劑、送S/Rota

    PS:

    英文名稱: glucose-6-phosphate dehydrogenase

    中文名稱: 葡萄糖六磷酸鹽脫氫酵素缺乏症

    簡稱縮寫: G6PD

    名詞解釋: 就是一般所講的蠶豆症。是患者體內缺少叫做葡萄糖六磷酸鹽脫氫脢 (G6PD;glucose-6-phosphate dehydrogenase) 的酵素活性的疾病。G6PD缺乏症是一種很常見的性連(X-link)遺傳的先天代謝異常疾病。G6PD是紅血球分解葡萄糖代謝過程中的一種重要的酵素。

    CBC:ccomplete blood count: 紅血球、白血球、血小板計數

    DC:differential count:白血球分類比(顆粒球、嗜酸性、嗜鹼性、淋巴球、單核球)

Still have questions? Get your answers by asking now.