Anonymous
Anonymous asked in 健康疾病與處置癌症 · 1 decade ago

內科英文病歷翻譯(急)

【病史過去、現在或家族史Medical history】

This 84 y/o women has history of diabetic mellitus under OHA and old CVA with left side weakness with bedridden.This time she had suffered from conscious disturbance in this noon and was brought to ER for help where blood glucose revealed 28 mg/dl and D50W 4 amp was given right away.But consciousness did not regain,brain CT was performed and r/o brain stem stroke.Lab data as followed: WBC of 12130 /uL,BUN/Cre of 20/1.0 mg/dl,CRP of 1.45 mg/dl and ammonia of 25 umol/L.Urine analysis showed 10-25/HPF of WBC and one plus of leukocyte.Soon intubation was performed for dyspnea with impending respiratory failure.Under the impression of r/o brain-stem stroke and respiratroy failure ,she was admitted to MICU for critical care and management.

Diabetes mellitus poor control

Coronary artery disease

Hypertensive cardiovascular disease

UGI bleeding

Urinary tract infection

【住院治療經過Course and Treatment】

This 84 y/o women has history of diabetic mellitus under & old stroke ,left side weakness & bed ridden under OAD therapy. She suffered from conscious disturbance on Aug.28, 2010. She was brought to our ER for help where blood glucose revealed 28 mg/dl, so D50W 4 amps were given at that time. Thereafter consciousness was not regain, brain CT was performed. Brain CT showed brain stem stroke. Lab data as followed: WBC of 12130 /uL,BUN/Cre of 20/1.0 mg/dl,CRP of 1.45 mg/dl and ammonia of 25 umol/L. Urine analysis showed 10-25/HPF of WBC and one plus of leukocyte. ETT intubation was done due to dyspnea and impending respiratory failure. Under the impression of brain-stem stroke and respiratory failure, she was admitted to MICU for critical care. Doripenem & Cravit were taken for urosepsis & pneumonia.Intermittent hemoptysis was noted by suction.

Because of poor weaning & ventilator, she was transferred to RCC for care

1 Answer

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  • 1 decade ago
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    1:這 84年/ Ø婦女有糖尿病史老下OHA的腦中風與左側的弱點與 bedridden.This一次她遭受了意識障礙,並在今天中午被送到急診室尋求幫助的地方血糖顯示 28毫克/ dl和D50W 4安培被賦予的權利 away.But意識並未恢復,進行腦 CT和R / O的腦幹 stroke.Lab數據如下:白細胞 1.213萬 / UL認證,尿素氮/肌酐的20/1.0毫克/分升,CRP水平1.45毫克/升和氨氮25 umol / L.Urine分析表明10-25/HPF WBC和一加leukocyte.Soon插管的呼吸困難和瀕臨呼吸failure.Under印象的R / O的腦幹中風和呼吸衰竭,她被送往內科加護病房護理和管理的關鍵。

    糖尿病控制不佳

    冠狀動脈疾病

    高血壓心血管疾病

    上消化道出血

    尿路感染

    2:糖尿病控制不佳

    冠狀動脈疾病

    高血壓心血管疾病

    上消化道出血

    尿路感染

    【住院治療經過課程與治療】

    這 84年/ Ø婦女有糖尿病病史及中風老人下,左側無力及長期臥床下OAD治療。她出現意識障礙的8月28日,2010年。她被帶到我們的急診室尋求幫助的地方血糖顯示 28毫克/分升,所以D50W 4安培分別給予那個時候。此後意識不恢復,腦 CT進行。腦 CT顯示腦幹中風。實驗數據如下:白細胞 12130 /微升,尿素氮/肌酐的20/1.0毫克/分升,CRP的1.45毫克/升和氨氮25 umol / L的尿液分析表明10-25/HPF WBC和一加白細胞。氣管內管插管做由於呼吸困難和瀕臨呼吸衰竭。在印象腦幹中風,呼吸衰竭,她被送往內科加護病房的重症監護。多尼培南及可樂必妥,以進行尿膿毒症及pneumonia.Intermittent咯血注意到了吸力。

    由於惡劣的斷奶及呼吸器,她被調到

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