Anonymous
Anonymous asked in 健康其他:保健 · 1 decade ago

[ 翻譯 ] 病歷+醫矚

主訴:consciousness disturbance was told by family this morning.

病史:This 94 y/o female has past history of 1.Hypertension 2.Diabetes mellitus 3.HCVD without regular medication control. She suffered form consciousness disturbance in this morning. Pool intake, chocking and passage tarry stool for recent were found by her family. So she was sent to our ER for help.

Physical examination showed: Conscious level GCS: E2V2M4.

Lab data: hyperglycemia and dehydraction,

U/A showed WBC : 60-80 / HPF,

Bacteric:4+ , lenky:1+, Nitrite: postive.

Brain CT showed suspicious lacunar infarct and arteriosclerosis.

Under the impression of 1.Urinary tract infection 2.糖尿病 poor control 3.高血壓 4.Suspect cerebral vascular accident..

So she was admitted to our ward for further evaluation and treatment.

過去病史:Disease (+) for 15 years with medication control, CVA history (+)

開刀史:NIL

<系統回顧>

眼睛:cataract(+)

心血管:高血壓、心雜音

Endocrine:糖尿病

Gastrointestinal tract:Poor appetite (+)

Neurologic:無力

檢體發現

精神意識:清楚

頭頸眼耳鼻:大致正常

瞳孔大小:左右皆2.5mm

瞳孔雙眼皆有對光反應

頸部:柔軟的

胸肺:Symmetric expansion (+)

心臟:1. Regular heart beat (+) 2.Heart murmur(+) GrII 3.PMI at the 5th intercostals

Abdomen:1. soft (+) flat (+) 2. Bowel sound: normo-active(+) 3. Percussion : tympanic

Extremities: freely morablt (+)

臨時醫囑:

5/18 = on Hn tube → hold]

= S / R

5/19 = HbAC (cm)

5/20 = bisadyl 10 mg 2# supp st

= bladder edho

5/21 = F/U U/A

長期醫囑:

5/19 = condition: guarded

= vital sign: QID

= Activity: bed-rest

= Allergy: NKA

= Diet: NG 1500 kcal / day + 鹽 3g / day

= Nursing:

= Record I/O QD

= On NG & Foley care QD

= Q2h changh position

= wound CD with pola QD

= IVF: 1.N/S bot ivd QD run 20 c.c / hour 不用pump

= 2. NACL 3% run 15 c.c / hour with pump

= Augcin (1.2gm) 1 amp Q8H

5/20 = NG diet 1500 kcal + 鹽 5gld

= 3% Nacl 500 c.c run 20 c.c / hour

2 Answers

Rating
  • 1 decade ago
    Favorite Answer

    consciousness disturbance was told by family this morning.

    由家屬告知病患在今晨有億識障礙的情形

    病史:94歲女性 過去病史 1.高血壓 2.糖尿病 3. C肝病史沒有規則用藥

    病患今晨被發現有億識障礙的情況 少進食 易嗆到 並且最近被家屬發現有解黑變的情況 所以他被送至急診尋求醫療協助

    Physical examination showed: Conscious level GCS: E2V2M4.

    體檢發現: 億識評估 GCS(就是昏迷指數):E2V2M4

    Lab data: hyperglycemia and dehydraction,

    實驗室數據: 高血糖及脫水

    U/A showed WBC : 60-80 / HPF,

    尿液分析: 白血球 每高倍顯微鏡下60-80顆

    Bacteric:4+ , lenky:1+, Nitrite: postive.

    細菌數:4+ leukocyte esterase: 1+ Nitrite: positive --->簡單的說就是 有泌尿道感染

    Brain CT 腦電腦斷層: 懷疑 很小的缺血性中風 以及血管硬化

    Under the impression

    根據以下的問題診斷: 1.泌尿道感染 2.糖尿病 控制不良 3. 高血壓 4.懷疑大腦血管問題

    被收住院進行評估及相關處置

    過去病史:

    某疾病 15年 有藥物控制 ,有腦血管方面的病史

    眼睛:cataract(+) 白內障

    心血管:高血壓、心雜音

    Endocrine內分泌:糖尿病

    Gastrointestinal tract腸胃道:Poor appetite (+) 少進食

    Neurologic神經學:無力

    胸肺:Symmetric expansion (+) 對秤性擴張

    心臟:1. Regular heart beat (+) 2.Heart murmur(+) GrII 3.PMI at the 5th intercostals

    1.規律心跳 2. 有心雜音GrII(稍微聽的道) 3. 最大新因是在第五肋間

    Abdomen:1. soft (+) flat (+) 2. Bowel sound: normo-active(+) 3. Percussion : tympanic

    腹部: 柔軟 平坦 腸音: 正常 扣診: 鼓音(正常)

    Extremities: freely morablt (+)

    四肢: 自由活動

    臨時醫囑:

    簡寫有點不清楚

    長期醫囑:

    5/19 = condition: guarded 狀況: 被保護

    = vital sign: QID check 生命現象一天四次

    = Activity: bed-rest 活動力:臥床

    = Allergy: NKA 無過敏病史

    = Diet: NG 1500 kcal / day + 鹽 3g / day 飲食: 鼻胃管灌食1500大卡/天1500 kcal / day

    = Nursing: 護理

    = Record I/O QD 每天記錄 攝入/排出量

    = On NG & Foley care QD 鼻胃管 及尿管照護

    = Q2h changh position 每兩小時換姿勢

    = wound CD with pola QD 傷口換藥每天一次

    = IVF: 1.N/S bot ivd QD run 20 c.c / hour 不用pump

    = 2. NACL 3% run 15 c.c / hour with pump

    = Augcin (1.2gm) 1 amp Q8H

    5/20 = NG diet 1500 kcal + 鹽 5gld

    = 3% Nacl 500 c.c run 20 c.c / hour

    Source(s): 常在打病歷的我
  • 1 decade ago

    我來補充臨時醫囑吧!

    5/18 = on Hn tube → hold] 看不懂?g是不是抄錯了? On NG tube(依病情來看,應該是on Ng tube補充營養,預防嗆到)

    = S / R stool routine 糞便常規檢查~~ 留便便檢查

    5/19 = HbAC (cm) 明天早晨抽糖化血色素(HA1C才對)糖尿病人必定要做的檢查

    5/20 = bisadyl 10 mg 2# supp st 臨時給藥bisady 10 mg塞劑2顆

    = bladder edho 應該是bladder echo(膀胱超音波吧)

    5/21 = F/U U/A follow up(F/U)urine analysis(U/A) 尿液常規檢查追蹤~~就是留小便做檢查啦

    多練習看,多問學姊或醫生(找慈祥一點的),久了就看懂啦!

    Source(s): 臨床工作10年看了無數本的病歷執行不少order
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