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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

醫囑(已經大概翻了一下)

已經大概翻了一下,麻煩高手再幫我修改一下,非常感謝。(可能有些單字有拼錯)

chief complaint:general weakness and short of breath for 5 days

主訴:呼吸衰弱5天

present illness:this 71-year-old male has diabetes mellitus hypertension,chronic renal insufficieucy,and old stroke and regularly followed from sudden onset general weakness on 9/25 and fell down with left hand support

本病:這71歲的男性糖尿病高血壓,慢性腎功能不足,9/29中風和從突發性全身無力由左邊侵導左手支撐,並定期追蹤。

there was no head injury,but short of breath was noted after then,cough with mild blood-stained sputum was also noted.

沒有任何頭部外傷,但呼吸短促,還指出輕度咳嗽痰沾滿鮮血。

there was no fever,chest pain,sore throat,rhinorrhea. chest tightness,abdominal pain,orthopnea,or cyanosis,he was brought to安泰hospital for help,elevated D-dimer(4068.36ng/ml)and CPK(3801 IU/L)were noted,but CK-MB and troponin-I was.relative low,besides, leukocytosis was also noted .under the impression of acute

沒有發燒,胸痛,喉嚨痛,流鼻涕。胸悶,腹痛, 心悸 ,或發紺,他被帶到安泰醫院尋求協助,注意到提高D -二聚體( 4068.36ng/ml )和肌酸磷酸激酶( 3801國際單位/ L ),但是肌酸酣活化槑酶及心肌旋轉蛋白相對是較低,此外,也注意到白血球急性下降。

coronary syndrome and suspected pulmonary embolism,the patient was transferred to our ER on 9/29. leukocytosis with elevated CRP,elevated D-dimer and CPK were noted.

chest X-ray showed increased infiltration at RUL and RLL and ECG-showed sinus rhythm with first-degree AV block. chest CT bilateral pleural effusion (more at right side).

冠狀動脈合併症,並懷疑肺栓塞,9 / 29病人被轉送至急診室 。白血球升高C反應蛋白,指出提高D -二聚體和肌酸磷酸激酶。

胸部X光片顯示,增加介白素滲透在右上肺葉和右下肺葉,心電圖顯示竇性心律第一度房室傳導阻滯。胸部斷層掃描胸腔左右兩邊都有積水(右邊比較多) 。

mald enlargement of lower paratracheal,subcarinal. and right hilar. lymph node. no obvious filling defect in pulmonary trunk and major pulmonary arteries was noted. under the impression of pneunonia,the patient was admitted to CVcard or further evaluation and management.

由鎖骨到舌骨之間得的中線區域,沒有擴大到氣管隆突下右肺門 。並指出淋巴結沒明顯的補充缺陷在肺動脈幹和主要肺動脈。接下來的印象是肺炎,病人被表示為CV card或進一步的評估和處理。

tracing back his history, the patient was insomnia recently,and he tack some over-the-counter drug to keep up his spirit on the day before the evene.

追溯他的病史,最近患者失眠,他甚至會購買成藥,以及每天都會喝烈酒, evehe 。

1 個解答

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  • TRUTH
    Lv 6
    1 0 年前
    最佳解答

    1,general weakness and short of breath for 5 days

    全身無力且呼吸急促 5天了

    2.and old stroke and regularly followed from sudden onset general weakness on 9/25 and fell down with left hand support

    陳舊性中風規律治療 9/25跌倒並用手撐住開始全身無力

    3.chest X-ray showed increased infiltration at RUL and RLL 右肺上葉及右肺下葉有浸潤現象

    4.mild enlargement of lower paratracheal,subcarinal. and right hilar. lymph node. no obvious filling defect in pulmonary trunk and major pulmonary arteries was noted. under the impression of pneunonia,the patient was admitted to CVward or further evaluation and management.

    較下位置的氣管兩旁 鎖骨下 右肺門和淋巴結有些過大 沒有明顯見到肺動脈幹和肺動脈血液填充上不足 根據上述診斷為肺炎 病人住進心臟科病房做後續評估喊處置

    5. 其他你都翻了 只是有些提供你參考

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