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

急~~~~~請'幫我翻譯一下醫囑!!

主訴 (Chief Complaint)

Syncope episode yesterday morning.

現在病症 (Present Illness)

This 55 years old male had history of

1.gouty arthritis with tophus formation

2.hypertension

3.chronic renal insufficiency

He had just received total hip replacement 1 week ago due to hip bone necrosis .

Since that time , he got poor appetite and felt nause when seeing food .

Besides , in recent days he got watery diarrhea 5-6 times a day .

No tarry stool or abdominal pain was noted .

Yesterday morning , he got syncope episode once when standing from chair .

Duration about 1 minute and no seizure was noted .

So he was sent to our ER for help .

At ER laboratory data showed no specific finding except leukocytosis , low serum sodium and potassium , elevated creatinine and CRP .

Unine analysis showed within normal range .

Chest film and KUB was performed which revealed no specific abnormality .

There was no heart disease before , no neuro focal sing , no trauma history , no nausea / vomiting , no cough , no urinary frequency , no dysuria , no oligouria were noted .

Under the impression of

1.syncopy , r/o dehydration related .

2.fever , cause to be determined , r/o infectious enterocolitic .

3.Acute on chronic renal insufficiency , he was admitted for further evaluation and management .

2 Answers

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  • 1 decade ago
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    主訴 (Chief Complaint)

    Syncope episode yesterday morning.昨天早上偶發性暈厥

    現在病症 (Present Illness)

    This 55 years old male had history of 55歲男性過去病史為

    1.gouty arthritis with tophus formation 痛風性關節炎併痛風石形成

    2.hypertension 高血壓

    3.chronic renal insufficiency 慢性腎臟功能不全

    He had just received total hip replacement 1 week ago due to hip bone necrosis .因骨頭壞死一週前剛接受過全髖關節置換術

    Since that time , he got poor appetite and felt nause when seeing food . 自那時起他食慾變差,看到食物覺得噁心

    Besides , in recent days he got watery diarrhea 5-6 times a day .

    No tarry stool or abdominal pain was noted .此外最近每天有5-6次的水樣腹瀉,但未提及瀝青狀便或是腹痛

    Yesterday morning , he got syncope episode once when standing from chair .昨天早上,他自椅子上起身時發生了一次暈厥

    Duration about 1 minute and no seizure was noted . 持續大約一分鐘且無癲癇情形

    So he was sent to our ER for help . 他被送進本院急診求治

    At ER laboratory data showed no specific finding except leukocytosis , low serum sodium and potassium , elevated creatinine and CRP .

    Unine analysis showed within normal range .在急診的實驗室報告顯示除了白血球增多,鈉鉀偏低,肌氨酸及C反應蛋白增加以外,並無特殊發現

    Chest film and KUB was performed which revealed no specific abnormality .胸部影像及KUB亦無特殊異常

    There was no heart disease before , no neuro focal sing , no trauma history , no nausea / vomiting , no cough , no urinary frequency , no dysuria , no oligouria were noted .過去無心臟疾病,無神經局部症狀,無創傷病史,無噁心及嘔吐,無咳嗽,無頻尿 解尿困難或寡尿情形

    Under the impression of 診斷如下

    1.syncopy , r/o dehydration related .暈厥,疑似脫水導致

    2.fever , cause to be determined , r/o infectious enterocolitic . 發燒,原因未明,疑似大腸小腸炎

    3.Acute on chronic renal insufficiency , he was admitted for further evaluation and management . 慢性腎功能不全的急性發作,入院做進一步評估及處置

  • Anonymous
    1 decade ago

    主訴(首要怨言) 昨天早晨中略語情節。 現在病症(當前病症) 這55歲男性有歷史 1.gouty與tophus形成的關節炎 2.hypertension 3.chronic肾功能不全他接受了總熟悉內情的替換1個星期前由于熟悉內情的骨坏死。自那時起,當看見食物时,他得到了恶劣的胃口並且感覺nause。其外,他近幾天來有水性腹泻5-6次每天。柏油凳子或胃腸痛苦未被注意。昨天早晨,當站立他從椅子时,曾经得到了中略語情節。期間大约1分鐘和沒有奪取被注意了。因此他派遣了到我們的幫助的ER。在ER實驗室數據沒有顯示具體發現除了白血球增多、低血清鈉和鉀、高的肌氨酸酐和CRP。 Unine分析在正常范围之內显示了。沒有顯露具體反常性的胸口影片和KUB執行了。沒有心脏病前面,沒有神經焦點唱歌,沒有精神創傷歷史,沒有噁心/嘔吐,沒有咳嗽,沒有泌尿頻率,沒有尿痛,沒有oligouria被注意了。在印象之下 1.syncopy, r/o失水關鍵。 2.fever,將確定的起因, r/o感染enterocolitic。在慢性肾功能不全的3.Acute,他為进一步評估和管理被录取了

    Source(s): .....
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