千雅 發問時間: 社會與文化語言 · 1 0 年前

這是一些病歷資料....希望有人可以幫忙翻譯....謝謝

這是一些病歷資料....希望好心人可以幫忙翻譯....謝謝

最好是專業人士回答,拒絕使用翻譯軟體的.....

感恩喔.....

主訴:

Progressed upper abdominal pain for recent days

病史:

This 25 y/o female is a well being before. According to her statement, she had suffered from intermittent upper abdominal pain for several years and the character of pain is discomfort to sharp pain, location : epigastric area, duration: persist pain. radiation pain: back(+), aggrevating factor : meal, supine position; relief factor: knee chest position, lateral position associated s/s include: nausea, vomiting, cold sweating, dyspnea, no fever, no chills, no hunger pain , no mid-night pain. Due to above reason, she visited our ER for help. At ER, Lipase: 733 was noted. Besides , abdominal CT revealed swelling pancrea, so under the impression of acute pancreatitis , she is admitted to our ward for management.

PH: DM (-), HTN (-)

drug taking (-)

op or hospital hx : denied

drug allergy : denied

DM (-), HTN (-)

體檢發現

conscious; clear

conj. : not pale , sclera: not icteric

Neck: supple, LAP(-), JAE(-)

chest: BS: bil. clear

HS: RHB, no murmur

Abdomen: soft, flat

tenderness over epigastric area , no rebound pain

BS: normoactive

EXT. : freely movable, no edema

治療過程:

After admission, routine survery was done. And NPO for Acute pancreatitis is also suggested firstly. Adequate fluid and nutrition supply is also given and pain control. After days of treatment, pain had relief much, nausea, vomiting also improved. After try diet is no problem, we let patient MBD and OPD F/U.

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病歷翻譯

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  • 1 0 年前
    最佳解答

    主訴:

    Progressed upper abdominal pain for recent days

    最近幾天上腹部愈來愈痛。

    病史:

    This 25 y/o female is a well being before. According to her statement, she had suffered from intermittent upper abdominal pain for several years and the character of pain is discomfort to sharp pain, location : epigastric area, duration: persist pain. radiation pain: back(+), aggrevating factor : meal, supine position; relief factor: knee chest position, lateral position associated s/s include: nausea, vomiting, cold sweating, dyspnea, no fever, no chills, no hunger pain , no mid-night pain. Due to above reason, she visited our ER for help. At ER, Lipase: 733 was noted. Besides , abdominal CT revealed swelling pancrea, so under the impression of acute pancreatitis , she is admitted to our ward for management.

    這是位之前健康狀態良好的25歲女性。依據他的主訴,他這幾年來都斷斷續續感到有上腹部疼痛情形,這種疼痛的特性是令人感到不適的尖銳性疼痛,位置:上腹部,持續時間:持續性疼痛,疼痛輻射部位:背部(+),加劇疼痛的因子:用餐、仰臥,減輕疼痛的因子:膝胸臥式、側臥,症狀/徵象包括噁心、嘔吐、冒冷汗、呼吸困難、無發燒、無寒顫,不會因飢餓而疼痛、半夜不會疼痛。由於上述理由,他到本院急診求診,脂肪分解酶733顯著升高,除此之外,腹部斷層掃描顯示胰臟腫脹,診斷為急性胰臟炎,所以入本院治療。

    Aggrevating是aggravating?!

    PH: DM (-), HTN (-) →病史:糖尿病(-),高血壓(-)

    drug taking (-)→服藥(-)

    op or hospital hx : denied →手術或住院史:否認

    drug allergy : denied→藥物過敏:否認

    DM (-), HTN (-)→糖尿病(-),高血壓(-)

    體檢發現

    conscious; clear →意識:清楚

    conj. : not pale , sclera: not icteric→結膜:無蒼白、鞏膜:無黃疸

    Neck: supple, LAP(-), JAE(-)→頸部:柔軟,淋巴結腫大(一)

    JAE是JVE?!JVE是頸靜脈怒張。

    chest: BS: bil. clear→胸部:兩側呼吸音清晰。

    HS: RHB, no murmur→心音:心跳節律正常,無雜音。

    Abdomen: soft, flat→腹部:柔軟,扁平

    tenderness over epigastric area , no rebound pain→上腹壓痛,無反彈痛。

    BS: normoactive→腸蠕動音:正常蠕動。

    EXT. : freely movable, no edema →四肢:活動自如、無水腫

    治療過程:

    After admission, routine survery was done. And NPO for Acute pancreatitis is also suggested firstly. Adequate fluid and nutrition supply is also given and pain control. After days of treatment, pain had relief much, nausea, vomiting also improved. After try diet is no problem, we let patient MBD and OPD F/U.

    入院後,常規檢查已做,治療急性胰臟炎首要是禁食,已告知,也已補充適當的體液和營養素,並予疼痛控制。治療數天後,疼痛以減輕許多,噁心、嘔吐也改善,試著進食後並無不適,故同意其出院並予門診追蹤。

    參考資料: ME
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