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匿名使用者
匿名使用者 發問時間: 社會與文化語言 · 1 0 年前

請各位大大幫小弟翻譯醫囑~~~急需

請大大幫我翻譯

(Family History)

Family history :non-contributory.

(Physical Examination)

Height and weight:cannot be measured 體溫:36.9脈搏:98呼吸:22血壓:130/70

Body height:162cm,Body weight:70kgw

General appearance:alertness with ill-looking

*skin:Senile skin turgor, no ecchymosis,no skin rash, no skin eruption, no skin lesions, no pressure sore.

*HEENT:pale conjunctiva(-),throat congestion(-),tonsils enlargement(-),pupil size:L/R 3mm/3mm,LR:L/R +/+

*Neck:supple & soft of neck, no JVE, no thyrocid goiter, no carotid brait.

*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.

*Chest:symmetric chest wall expansion, no spider angioma;percussion: no resonant. auscultation: bilateral diffuse wheezing, no crackle.

*Abdomen:soft and ovoid, no caput medusa, 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 or cyansis, Gr II 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:radio++/++,brachial++/++,post tibial++/++,dorsal pedial++/++

NEU examination:no remarked findings, GCS:E4V5M6,cranial nerve=intact,MD:5/5,DTR:++/++,essential normal sensory system,Babinski's sign:absent, bil

*Digital examination:no significant finding.

--------------------------------------------------------------------------------------

(Tentative Diagnosis)

*Chronic obstructive pulmonary disease with acute exacerbation.

*Hypertension cardiovascular disease.

*Edema of leg, bilateral

(Plan of Management and Treatment)

check SMA, U/R

Arrange chest sonography

Arrange Echocardiogram(1800 5B+1800 7B)

IV fluid supplement with close observation

Control blood pressure level

Conservative treatment with close observation

2 個解答

評分
  • 1 0 年前
    最佳解答

    可以先去讀一下相關評估:

    http://www.cgmh.org.tw/intr/intr2/c3100/pub/18info...

    http://203.75.23.151/mynuke/score/gcs.htm

    由於前段和我回答的這題有相似處...

    http://knowledge.yahoo.com.tw/question/question?qi...

    所以請你先瀏覽一下該題

    後半段在爲您補足:

    (Tentative Diagnosis)初步診斷

    *Chronic obstructive pulmonary disease with acute exacerbation.慢性阻塞性肺疾急性惡化

    *Hypertension cardiovascular disease.高血壓性心血管疾病

    *Edema of leg, bilateral雙側腿部水腫

    (Plan of Management and Treatment)處置及治療計畫

    check SMA, U/R抽血驗抗平滑肌抗體(SMA可能是一些專有名詞的縮寫,但此處應指smooth muscle autoantibody) 及作尿液常規檢驗Arrange chest sonography安排胸腔超音波

    Arrange Echocardiogram(1800 5B+1800 7B)安排心臟超音波(後面應該是醫院的檢查代碼)

    IV fluid supplement with close observation靜脈點滴補充並密切觀察

    Control blood pressure level控制血壓

    Conservative treatment with close observation 保守(姑息)療法並密切觀察

    參考資料: 醫護背景
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  • 1 0 年前

    我只知第一個是 家史ㄟ!

    對不起囉

    你可以到雅虎的字典

    案段落翻譯久好了

    我建議你一句句打

    步然會讀過久

    參考資料:
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