請醫護人員幫我翻譯醫囑!!15點

Gingira swelling with easily bleeding and oral ulcer were noted later.

Patient visited LMD where pancytopenia with left shift, macrocytic anemia

(4/15 Hb:8.8 Mcv:105.8 WBC:2300 seg:25.8% Lym:62.7% mono:10.4% EO:0.3% Baso:0.8 platelet:76000)

were noted , Then he was transferred to ER of Hsin Chu Hospital (Department of Health Executive Yuan) on 0419 , unknow blood transfusion was done and then diacharged.

Patient visited Hematology Dr.chang’s clinice on 4/20,where 7% B’W loss in one month was noticed (70-65kg). Bone marrow biopsy with interpretation , bone marrow iron stain and blood smear inter pretation was done on 4/21

Patient was abmitted and received antibiotic treatment for Pnumonia.

RT-PCR revealed AML-ETO(-).CBFb-MYH11(-). and MLL-PTD(-).Bone marrow chromosomal oberration study.acute leukemia maker,and TDT exam were done. Fever pesisted especially in the afternoon.

Patient visited our OPD and received oral antibiotics (ciprofloxacin). The fever mildly decreased. Due to the residual fever episode,patient was admitted for further inrestigation and treatment.

Past History :

1.Acute myeloid leukemia with myelody splstic feature .

2.DM(HbA1c:9%.200904)

Personal History:

Allergy:nka

Alcohol(Denied)

Keep smoking for>50 years.

Family History:Non contributsry.

Review of system:

Genral:

Appearance: fair looking Consious :clear.

Dereioment: fair weakness : (no)

Fatigue : (no) Fever: (intermittent) chill: (no)

Neck:stiffness: (no)

Resp Sys:Dyspnea: (after walking for short diastance and climbing upstairs)

Wheezing : (no) cough: (no) sputum: (no) Hemoptysis: (no)

Cv: chest tightness : (no) chest pain (no) Exertional dyspnea : (yes) Orthopnea(no)

P.N.D(no) palpitation (no) Tachycardia(persisted) Bradycardia (no)

1 Answer

Rating
  • 1 decade ago
    Favorite Answer

    齒齦腫脹,容易出血和口腔潰瘍後指出。

    病人曾經在去外院看診診斷全血細胞減少症與左移,巨紅細胞性貧血 ( 4月15日血紅蛋白: 8.8紅細胞: 105.8白細胞: 2300秒: 25.8 %淋巴細胞: 62.7 %單: 10.4 % 13224 : 0.3 % Baso : 0.8血小板: 7.60萬)

    那裡記錄,他從急診被轉診至新竹醫院(衛生署行政院)在四月十九日 ,未知血液報告(血液輸液)出院 。

    病人訪問血液分析Dr.chang’s 的診所在4月20日,其中7 % 體重在最近一個月掉了( 70~ 65公斤) 。骨髓細胞檢查解釋,骨髓鐵染色和血塗片間所做的詮釋在4月21日

    病人是入院和接受肺炎抗生素治療。

    RT - PCR檢測發現白血病的ETO ( - ) 。 CBFb - MYH11 ( - ) 。和MLL -早產( - ) 。骨髓白血病染色體oberration study.acute製造商,並進行了原位考試。熱pesisted尤其是在下午。

    病人訪問了我們的門診,並得到口服抗生素(環丙沙星) 。發燒輕度下降。由於殘餘熱插曲,病人入院接受進一步檢查和治療。

    過去病史:

    1.急性髓細胞性白血病與myelody splstic功能。

    2.糖尿病 (糖化血紅蛋白: 9 % 0.200904 )

    個人病史:

    過敏:無

    酒精(無)

    持續抽煙大於50年之久。

    家族史:非contributsry 。

    身體檢查:

    全身:

    外觀:情況檢視意識 :清楚。

    Dereioment :情況虛弱: (沒有)

    疲勞: (沒有)發燒: (間歇)寒憻: (沒有)

    頸部:僵硬: (沒有)

    呼吸系統:呼吸困難: (短程步行和爬山樓上)

    喘息: (沒有)咳嗽: (沒有)痰: (沒有)咳血: (沒有)

    簡歷:胸悶: (沒有)胸痛( NO )運動性呼吸困難: (是) 端坐呼吸 (沒有)

    PND (無)心悸( NO )心室動過速(堅持)心動過緩(沒有)

Still have questions? Get your answers by asking now.