可以幫我翻譯Admission Note嗎!!(第3章)

(Family History)

Family history: non-contributory.

(Physical Examination)

* Vital sign: BT=37.8℃, PR: 20/min, BP115/81mmHg

* General appearance: alertness with ill-looking

* SKIN: normal skin turgor, ecchymosis over left ankle and foot, no skin rash, skin

eruption, no skin lesions, no pressure sore.

* HEENT: pale conjunctiva (+), icteric sclera (-), throat congestion (-), tonsils

enlargement (-), pupil size: L/R 3mm/3mm, LR:L/R +/+

* Neck: supple & soft of neck, no JVE, no thyroid goiter, no carotid bruit.

* Heart: regular HB, S1→ ; S2→, no S3/S4, Gr. 2/6 systolic murmur on apex and

LSB, no thrill, PMI in Lt 5th ICS lat-to mid-clavicular line.

* Cheat: symmetric cheat wall expansion, no spider angioma ; percussion: no

resonant. auscultation: Coarse BS, no rhonchi, no wheezing, no basal rales.

* Abdomen: soft and oveid, no caput meduse, normal bowel sound, no shifting

dullness, no local tenderness, no palpable liver or spleen, no Murphy sign, no

muscular rigidity.

* Genitourinary: no hernia, no C-V angle knocking tenderness

* Extremities: no clubbing cyansis, No pitting edema, no varicose vein of bil low legs,

no joint deformities and full range of motion, no bone, joint, or muscle tenderness

* Peripheral pulsations: radial ++/++, branchial, ++/++, post tibial , ++/++, dorsal

pedial ++/++

* NEV examination: no remarked findings, GCS=E4V5M6, cranial nerve=intact,

MP=3/5, DTR=++/++, essential sensory system, Babinski’s sign: absent, bil

* Digital examination: no significant finding.

(Tentative Diagnosis)

1.Fever and poor appetite, cuase?

2.Type 2 diabetes mellitus with poor control

3.Liver cirrhosis with esophagus varies, moderate splenomegaly and mild ascites. Child A

4.Peptic ulcer disease

5.Chronic ulcer, L’t heel with necrotizing fascitis post operation

6.Old cerebral infarction with right hemiparesis.

(Plan of Management and Treatment)

Check SMA, U/R, Hgb AlC

IV fluid supplement with close observation

我知道很多,但幫幫忙!!

拜託拜託!!

1 個解答

評分
  • Dawn
    Lv 5
    1 0 年前
    最佳解答

    (家族病史)

    家族病史;無

    身體檢查

    *生命徵像;體溫37.8度c,呼吸20次/分鐘,血壓115/81mmHg

    *一般樣貌;警覺及生病樣

    *皮膚;正常皮膚組織,左腳踝及足部有瘀斑,無皮膚疹,皮膚出疹,無皮膚損傷,無壓瘡

    *HEENT:結膜蒼白,無鞏膜黃膽,無喉嚨充血,無舌腫大,瞳孔大小;左右都為3mm大小,雙眼瞳孔皆有反射

    *頸部;頸部彈性柔軟,沒有頸靜脈怒張,無甲狀腺種大,無頸動脈雜音

    *心臟;規律心跳,第一第二心音,無第三第四心音,心尖及左胸骨緣在心收縮期有心雜音,無震顫,心博最高點在左側第五肋間心血管中線

    *胸;胸壁對稱擴張,無蜘蛛狀血管瘤,扣診;無回響音,聽診;呼吸音粗囉音,無爆裂音,無喘鳴音,無基底囉音

    *腹部;柔軟無腫塊,腸音正常,無移動性濁音,無壓痛,摸不到肝臟或是脾臟(表示無肝脾腫大),無墨非徵像(無膽囊炎),無肌肉僵硬

    *生殖泌尿器;無疝氣,無骨盆角壓痛

    *四肢;無發紺,無凹陷性水腫,雙下肢無靜脈曲張,關節無變形,關節動度正常,骨頭及關節或是肌肉無壓痛.

    *周圍動脈搏動;橈動脈雙側兩價,鰓動脈雙側兩價,後脛骨雙側兩價,足背動脈雙側兩價

    神經學檢查;無特別發現,意識評估;睜眼4分語言5分運動6分(為滿分),腦神經=完整,肌肉力量3/5分,深腱反射雙側皆為兩價,基本感覺系統,巴比斯金反射(腳底反射);雙側皆無

    *照相檢查(應該是說x光吧);無發現

    試驗性的診斷

    1.發燒合併食慾差原因不明

    2.第二型糖尿病合併控制不良

    3.肝硬化合併食道變化,中度的脾臟腫大及少量的腹水,child A好像是個分級或是分類

    4.消化性潰瘍

    5.左足跟慢性潰瘍合併壞死曾施行手術

    6.陳舊性腦血管阻塞合併右側偏癱

    (治療計畫及治療)

    抽血檢查生化,尿液檢查,糖化血色素檢查

    靜脈輸一給予以及密切的觀察

    參考資料: 護理人
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