�楊 發問時間: 社會與文化語言 · 1 0 年前

病歷翻譯 很急

病歷翻譯...很急..拜託

post history

1.Diabetes mellitus..denied

2.Hypertension +

3.Hepatitis B or C infection ..deined

4.Other systemic disease . denied

CVA history 2007.6

physical Examination

vital sign

HENNT conjunctiva not pale sclera ...anicteric

Neck ..supple lymphadenopathy- jugular vein engorgement-

thyroid ...impalpable

chest ...symmetric expansion breath with accessory muscle use-

spider angioma-

Heart sound ...regular heart beat no murmur

breath sound ..bilateral clear ..no wheezing no crackle

Abdomen ...softand flat no thnderness operation scar-

Bowel sound ..normoactive percussion..dullness-

Liver/spleen ..impalpable shifting dullness-

Muscle rigidity- Rebound tenderness-

Norphy's sing- Mcburney's sign-'

Costo--vertebral knocking pain R/L -/-

eXTREMITIES ..LEFT SIDE HEMIPLEGIA

skin; intact rash- petechiae- ecchymosis-

*CRNANIA NERVES

I;smell.not test

II;VISUAL ACUITY ..NOT TEST

VISUAL FIELDS ..NOT TEST

III.. IV...VI....;pupils'3/3mm light reflex+/+

EOM ...free

nystagmus

diplopia

ptosis left

accommodation ..intact

V;masseter..powerful

facial sensation

VII;MILD CENTRAL TYPE FACIAL PALSY

V I I I ;hearing..intact

IX.X;uvula position ..central

XI;sternocl eidomastoid and trapezius

XII;tongue deviation -

tongue atrophy-fibrillation-

2 個解答

評分
  • 1 0 年前
    最佳解答

    post history病史

    1.Diabetes mellitus..denied糖尿病(沒有)

    2.Hypertension + 高血壓 (有)

    3.Hepatitis B or C infection ..deined B或 C型肝炎感染 (沒)

    4.Other systemic disease . denied 其他系統疾病 (沒)

    CVA history 2007.6 (腦血管疾病史自2007年六月)

    physical Examination (身體檢查)

    vital sign 生命現象

    HENNT conjunctiva not pale sclera ...anicteric 無黃疸

    Neck ..supple lymphadenopathy- jugular vein engorgement-

    thyroid ...impalpable 甲狀腺 -難以識別

    chest ...symmetric expansion breath with accessory muscle use- 胸—呼吸勻稱

    spider angioma- 血管瘤

    Heart sound ...regular heart beat no murmur 心音: 正常無雜音

    breath sound ..bilateral clear ..no wheezing no crackle 呼吸:兩邊清楚

    Abdomen ...softand flat no tenderness operation scar- 腹部: 軟且扁平,沒有手術疤痕

    Bowel sound ..normoactive percussion ..dullness- 內臟: 扣診遲鈍

    Liver/spleen ..impalpable shifting dullness- 肝脾 –難以識別的轉遲鈍。

    Muscle rigidity- Rebound tenderness-肌肉強度—回彈力弱

    Norphy's sing- Mcburney's sign-' Norphy氏症,Mcburney氏症,均無

    Costa -- vertebral knocking pain R/L -/-肋骨 –脊柱 敲擊痛覺 (左右均無)

    eXTREMITIES ..LEFT SIDE HEMIPLEGIA 左半身不遂

    skin; intact rash- petechiae- ecchymosis- 皮膚:正常

    *CRNANIA NERVES腦神經測試:

    I;smell.not test第 1對,嗅覺,沒作測驗

    II;VISUAL ACUITY ..NOT TEST VISUAL FIELDS ..NOT TEST第2:視覺,視野,沒作測驗

    III.. IV...VI.. 第3, 4, 6對,..;pupils'3/3mm瞳孔:3/3mm, light reflex+/+對光有反射反應,EOM ...free眼球可自由轉動,nystagmus眼球震顫(症),diplopia 複視 (雙重影像),ptosis left 左眼瞼下垂,accommodation ..intact 調節正常

    V;masseter..powerful facial sensation第5對:顏面知覺: 強

    VII;MILD CENTRAL TYPE FACIAL PALSY第7對:輕微麻痺,

    V I I I ;hearing..intact第8對:聽力正常

    IX.X;uvula position ..central第9,,10對 懸壅垂位置:居中,(正常)

    XI;sternocl eidomastoid and trapezius????

    XII;tongue deviation -第12對,舌偏

    2007-12-18 09:11:28 補充:

    檢查項目後( )內(+)表示有 , (-)表示沒有, denied 表示否認, 也就是病人自述沒有

    參考資料: myself-修過相關課程
  • 匿名使用者
    1 0 年前

    張貼歷史

    1.Diabetes mellitus..denied 2.Hypertension 3.Hepatitis B

    或C 傳染..deined 4.Other 系統疾病。denied CVA 歷史2007.6 體格檢查重要標誌HENNT 內眼膜不蒼白sclera... anicteric 脖子..supple lymphadenopathy- 頸部的靜脈engorgement 甲狀腺... 難以捉摸的胸口... 相稱擴展呼吸以輔助肌肉使用蜘蛛血管瘤心臟聲音... 規則心跳沒有私語呼吸聲音..bilateral..no 喘息爆裂聲腹部... softand 艙內甲板沒有thnderness 操作結疤腸聲音..normoactive percussion..dullness-Liver/spleen..impalpable 轉移的鈍澀肌肉堅硬反彈柔軟Norphy's 清楚不唱Mcburney 的標誌- ' Costo -- 椎骨敲的痛苦R/L -/- 肢..LEFT 旁邊偏癱皮膚; 原封輕率petechiae- ecchymosis *CRNANIA 神經I;smell.not 測試II;VISUAL 敏銳..NOT 測試視野..NOT 測試III. 。IV... vi....;pupils'3/3mm 輕的反射/EOM... 自由眼顫複視ptosis 留給適應..intact V;masseter..powerful 面部感覺VII;MILD 中央型面部痲痺v 我我I;hearing..intact IX.X;uvula 位置..central XI;sternocl eidomastoid 和trapezius XII;tongue 偏差- 責罵萎縮原纖維形成作用

    分---格---線

    不知道對不對~

    =口=網路資料可能有時會不準

    參考資料: 網路×
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