思婷 發問時間: 社會與文化語言 · 1 0 年前

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主訴:

left index finger amputation injury by electric fan on 96/6/2night

現在病症:

this 30-year-old man presented to our ER because left index finger amputated by electric fan around PM1030 on 96/6/2/ night .

initially , he was sent to LMD for medical aid .

then for further management.

smoking: 1PPD for years .

alcochol consumption :social

家族史:

non contributory

理學檢查:

general appearance:acute ill-looking

consciousness:clear

heent:

pupils size:2/2mm with light reflex :+/+

sclera(icterrus):no icterus

conjunctiva(pale):no pale ,red

neck:

free movement:full movement , no stiffness

mass:no palpable mass

no J.V.E no lymphadenopathy

chest:

breath pattern:smooth , regular

in spection :symmetric expansion

percussion:reasonance

breathing sound: bilateral clear breathing sound

heart:

regular heart beat

abdomen:

inspection:flat

bowel sound:normoactive BS

percussion:dullness , no shifting dullness

palpation:soft , no rigitidy , no tenderness , no muscle guarding

extremities:

left index finger ampuation , level at PIP joint

skin:

no pigmentation , no rash , no petechiae or ecchymosis

1 個解答

評分
  • shahad
    Lv 4
    1 0 年前
    最佳解答

    主訴:

    left index finger amputation injury by electric fan on 96/6/2night

    在96年6月2號時, 左手食指被電扇(電風扇)切斷

    現在病症:

    this 30-year-old man presented to our ER because left index finger amputated by electric fan around PM1030 on 96/6/2/ night .

    這位30歲的男性被送到我們的急診室因為他的左手食指在96年6月2號晚上大約在10:30左右時被電扇(電風扇)切斷

    initially , he was sent to LMD for medical aid .

    then for further management.

    smoking: 1PPD for years .

    剛開始的時候 他被送到一般診所治療. 然後在加以處理

    是否抽煙:: 每天一包---已多年

    alcochol consumption :social

    是否喝酒: 偶爾交際的時候會喝

    家族史:

    non contributory

    沒有提供

    理學檢查:

    general appearance:acute ill-looking

    病患臉色: 非常不好

    consciousness:clear

    意識: 清醒

    heent:

    pupils size:2/2mm with light reflex : /

    sclera(icterrus):no icterus

    conjunctiva(pale):no pale ,red

    heent:

    瞳孔大小:2/2mm 加上纖維的反射

    鞏膜(黃疸): 無黃疸

    結膜:紅色

    neck:

    free movement:full movement , no stiffness

    mass:no palpable mass

    no J.V.E no lymphadenopathy

    脖子:

    可以自由的移動: 完全的活動, 沒有僵硬的現像

    沒有淋巴腺病

    chest:

    breath pattern:smooth , regular

    in spection :symmetric expansion

    percussion:reasonance

    breathing sound: bilateral clear breathing sound

    胸部:

    呼吸情況: 順暢有規則

    檢查:均衡的擴展

    叩診: 共鳴

    呼吸的聲音: 清楚

    heart:

    regular heart beat

    心臟

    心跳正常

    abdomen:

    inspection:flat

    bowel sound:normoactive BS

    percussion:dullness , no shifting dullness

    palpation:soft , no rigitidy , no tenderness , no muscle guarding

    腹部:

    檢查: 平袒的

    內臟探測: 什麼是BS?

    叩診: 不明顯的 無移位的

    觸診: 柔軟並無堅硬處, 無肌肉無緊繃

    extremities:

    left index finger amputation , level at PIP joint

    四肢:

    左手食指切斷, 什麼是PIP? 

    skin:

    no pigmentation , no rash , no petechiae or ecchymosis

    皮膚:

    沒有色素, 疹子, 瘀斑, 或是瘀點

    參考資料: 有一些專有名詞我有可能翻的不恰當 請做參考
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