小薰 發問時間: 社會與文化語言 · 1 0 年前

急!!!請專業人士幫我翻譯會診的醫學英文!

可以告訴我為什麼我的個案要F/U CXR嗎?

(一)F/u CXR Clinical information

Pacth lesions are seen at right lung. chest tube is noted at right hemithorax. Subcutaneous emphysema is noted at right side. emphysematous change is noted at both lung. no enlargement of heart size is seen. A catheter is seen at mediastinum.

結果:

1.lung cancer

2.Malignant neoplasm of bronchus and lung,unspecified

3.Obstructive chronic bronchitis with acute exacerbation

4.Chronic ischemic heart disease,unspecified

PA view-standing(1),Chest

(二)consult CV

Brief History and Clinical Findings:

Dear Dr:Sincerely refer a 79 y/o patient to you. This patient was admitted to our ward with the chief problems as:

1.Adenocarcinoma of RUL,T2N2M0,stage IB

2.CHF

present problems that request your evaluation and management are:Short of breath

Consultation Finding and Recommendations

To Dr:This 79 y/o male patient and history of COPD,HCVD and ischemic heart disease.He was admitted for lung cancer (RUL),and received operation(wedge resection of RUL)on 97/8/6.Hower,he developed worsening dyspnea after operation.cough with yellowish sputum was also noted.

Chest:decreased breath sound of right lung

Heart:RHB No leg edema

EKG(97/7/31):left axis deviation

CXR:infiltration at right lung

97/8/1 cardiac echo:mild LVH with Normal LV contractility,moderate AR

Impression:

1.Keep Moduretic,DC Lanoxin

2.Add herbesser 1* po tid,Bormol 0.5* po bid

3.Follow EKG

4.May Do free charge cardiac echo for follow-up

5.Treat COPD

6.CV OPD follow up after discharge remove C/T

拜託了! 請完整呈現,謝謝!

1 個解答

評分
  • 1 0 年前
    最佳解答

    Pacth lesions are seen at right lung.   右肺有損偒

    chest tube is noted at right hemithorax.  右側血胸需要放胸管

    Subcutaneous emphysema is noted at right side.  右側有皮下氣腫

    emphysematous change(chest?) is noted at both lung. 雙肺有桶狀胸

    no enlargement of heart size is seen.  沒有看到心臟有擴大情形

    A catheter is seen at mediastinum.在縱隔腔有心導管的支架(病人可能曾做過心導管)

    結果:

    1.lung cancer:肺癌

    2.Malignant neoplasm of bronchus and lung,unspecified 

      在支氣管及肺有不明原因的惡性腫瘤

    3.Obstructive chronic bronchitis with acute exacerbation

      慢性阻塞性支氣管炎合併急性發作

    4.Chronic ischemic heart disease,unspecified 不明原因的慢性缺血性心臟疾病

    2008-08-30 21:44:05 補充:

    (二)consult CV 會診心臟科

    This patient was admitted to our ward with the chief problems as:這個病人是因為下列問題住院

    1.Adenocarcinoma of RUL 右側中下肺葉有肺腺癌

     T2N2M0,stage IB (是癌症的分期)

    2.CHF 慢性心衰竭

    present problems that request your evaluation and management are:Short of breath

    現在需要請你評估及處理的問題是:呼吸喘

    2008-08-30 21:44:21 補充:

    Consultation Finding and Recommendations 會診結果及建議

    This 79 y/o male patient and history of COPD,HCVD and ischemic heart disease.

    這個79歲的男性病患有 : 慢性肺部病疾病,高血壓性心臟病及缺血性心臟病的病史

    He was admitted for lung cancer (RUL),他是因為右側中下肺葉肺癌而住院

    and received operation(wedge resection of RUL)on 97/8/6. 

    以及在97年8月6日接受手術(右側中下肺葉切除術)

    2008-08-30 22:10:18 補充:

    Hower,he developed worsening dyspnea after operation.

    但他在手術後病情有惡化成呼吸困難的情形發生

    cough with yellowish sputum was also noted. 有咳嗽及黃痰

    Chest:decreased breath sound of right lung 胸部評估:右側呼吸音減少

    Heart:RHB No leg edema 心臟評估:腿部沒有水腫情形

    2008-08-30 22:11:26 補充:

    EKG(97/7/31):left axis deviation 心電圖:左軸偏離

    CXR:infiltration at right lung  右肺有侵潤

    97/8/1 cardiac echo:mild LVH with Normal LV contractility,moderate AR

    心臟超音波:輕微左側心室肥大以及正常的左心室收縮,中度AR(AR的中文忘了,自己去查縮寫字典)

    2008-08-30 22:21:53 補充:

    Impression:建議

    1.Keep Moduretic,DC Lanoxin --繼續使用Moduretic這個藥物,停止使用Lanoxin

    2.Add herbesser 1* po tid,Bormol 0.5* po bid --加上 Herbesser 1* po tid,Bormol 0.5* po bid使用

    3.Follow EKG --追踪心電圖

    2008-08-30 22:22:13 補充:

    4.May Do free charge cardiac echo for follow-up 也許可以再追踪不用計價的心臟超音波

    5.Treat COPD 治療慢性阻塞性肺部疾病

    6.CV OPD follow up after discharge remove C/T 出院後心臟科門診追踪治療,移除心導管支架

    2008-08-30 22:24:08 補充:

    P.S.病人都出現呼吸困難的問題,當然要追踪CXR

    參考資料: 自己
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