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

那位大大可以幫我翻譯一下這個病歷!!!

Admission Diagnosis:

1.Inhalation injury

2.Burst our fracture of L1

3.Calcaneus fraction, left

Discharge Diagnosis:

1.Inhalation injury

2.Burst our fracture of L1

3.Calcaneus fraction, left

4.Spinal cord injury

Chief Complaint:

Victim in a fire

Brief History:

This 32 y/o man got falling from height injury at a fire and inhalation

on xx/01/10 and received T12-L1 spine decompression and internal

fixation at Taipei municipal hospital for initial presentation of

paraplegia and transferred to our burn ICU for inhalation injury

treatment.

Physical Examination:

Cons: clear

Clear breathing sound

Regular heart beat, no murmur

Abdomen: soft and flat, liver/ spleen: impalpable

Ext: no cyanosis or edema

Numbness, L1-L2 dermatome, anesthesia L3-S2

Muscle power R't L't

Iliopsoas 0-1 0-1

Quadriceps 0 0

TA 0 0

EHL/FHL 0 0

Anal sphincter function(-)

Urinary incontinence

Left ankle swelling

Course and Treatment:

He was kept intubated and the pulmonary function improved.

Extubation was performed on 1/16 and he was transferred to

orthopedic ward for further management.

Laboratory

Radiology:

CT(xx/01/15): Extremities without contrast-

1.Comminuted calcaneal Fx. The other joint of foot can not be well

evaluated in this study.

2.Left foot swelling.

3.s/p transpedicle instrument fixation

4.Multiple linear Fx. Line in L1 with compression of 1/3diameter of

spinal canal.

Discharge Status:

Improved and transferred.

Recommendation & Medications:

Transferred to orthopedic ward for further management of multiple

fractures.

4 個解答

評分
  • 1 0 年前
    最佳解答

    Admission Diagnosis入院診斷:

    1.Inhalation injury吸入創傷

    2.Burst our fracture of L 1 L 1

    L 1 L 1有Burst our骨折

    3.Calcaneus fraction, left

    左跟骨折斷

    Discharge Diagnosis出院診斷::

    1.Inhalation injury吸入創傷

    2.Burst our fracture of L 1 L 1骨折

    3.Calcaneus fraction, left左跟骨折斷

    4.Spinal cord injury脊髓創傷

    Chief Complaint主訴:

    Victim in a fire火傷

    Brief History簡史:

    This 32 y/o man got falling from height injury at a fire and inhalation on xx/01/10

    該名32男性於某年/01/10由高處墬下落入火中受傷兼有吸入創傷

    and received T12-L1 spine decompression and internal

    fixation at Taipei municipal hospital for initial presentation of

    paraplegia and transferred to our burn ICU for inhalation injury treatment.

    並在半身不遂病發初期曾於臺北市立醫院接受脊椎減壓與內部固定手術,

    因吸入性創傷再轉至本院燒燙傷加護病房治療。

    Physical Examination物理診察:

    Cons: clear神智:清醒

    Clear breathing sound呼吸無雜音

    Regular heart beat, no murmur心跳正常無呻吟

    Abdomen: soft and flat, liver/ spleen: impalpable

    下腹部:柔軟平坦,肝臟及脾臟:無法觸知

    Ext: no cyanosis or edema

    外觀:無蒼白或浮腫

    Numbness, L1-L2 dermatome, anesthesia L3-S2

    麻木,皮膚知覺1级~2级,感覺麻痺3级~2级

    Muscle power R't L't

    左右肌力

    Iliopsoas 0-1 0-1

    骨客 腰肌(由大腿下方向上延伸至股骨後方的一條強力肌肉)右 0-1 左0-1

    Quadriceps 0 0

    四頭肌 右 0 左0

    TA 0 0

    (對不起,這個簡寫我不懂)右 0 左0

    EHL/FHL 0 0

    (對不起,這個簡寫我也不懂) 右 0 左0

    Anal sphincter function(-)

    肛門括約肌功能(-)

    Urinary incontinence

    尿失禁

    Left ankle swelling

    左足踝腫脹

    Course and Treatment:

    療程與施治:

    He was kept intubated and the pulmonary function improved.

    曾經維持插管,肺功能有改善

    Extubation was performed on 1/16 and he was transferred to

    orthopedic ward for further management.

    1/1完成拔管再轉入整形外科病房作進一步處理

    Laboratory

    檢驗室

    Radiology:

    放射科:

    CT(xx/01/15): Extremities without contrast-

    年/01/15 電腦斷層掃描:四肢無對照

    1.Comminuted calcaneal Fx. The other joint of foot can not be well evaluated in this study.

    後腳跟搗碎骨折,足部其餘關節在本診察中無從仔細評估

    2.Left foot swelling.

    右腳腫脹

    3.s/p transpedicle instrument fixation

    s/p transpedicle器械固定

    4.Multiple linear Fx. Line in L1 with compression of 1/3 diameter of

    spinal canal.

    多重線性骨折,L1裂痕伴隨脊椎管直徑1/3之壓縮

    Discharge Status:

    出院狀況:

    Improved and transferred.

    改善後轉院

    Recommendation & Medications:

    建議與給藥

    Transferred to orthopedic ward for further management of multiple fractures.

    轉往整形外科病房進行多重骨折進階治療

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  • 4 年前

    Orthotist

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  • 匿名使用者
    1 0 年前

    作業要自己寫喔~!

    至少試著自己寫寫看, 然後請大家幫你改正啊~

    不然以後怎麼在社會上和別人競爭呢?

    加油吧!

    不要拿病人的生命開玩笑~

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  • 1 0 年前

    承認診斷︰

    1.吸入傷

    2.衝破我們的L1的裂縫

    3.Calcaneus 小部分,離開

    卸診斷︰

    1.吸入傷

    2.衝破我們的L1的裂縫

    3.Calcaneus 小部分,離開

    4.脊髓傷

    主要的抱怨︰

    在一場火災裡的受害者

    簡短歷史︰

    這個32 y/o 人開始在一場火災和吸入從高度傷上掉下來

    在xx / 01/10上既沒得到和內部的T12-L1脊骨減壓

    固定在台北市政醫院適合最初演出

    截癱和為吸入傷轉移到我們的燒傷ICU

    處理。

    體檢︰

    記誦︰ 清楚

    清楚的呼吸的聲音

    有規律的心臟跳動,沒有喃喃聲

    腹部︰ 柔軟和平,肝/脾臟︰ 摸不著

    Ext︰ 沒有cyanosis或者水腫

    麻木,L1-L2 dermatome,麻醉L3-S2

    肌肉能力R't L't

    Iliopsoas 0-1 0:-1

    Quadriceps 0 0

    TA 0 0

    EHL/FHL 0 0

    臀鬆緊口裝置功能(-)

    小便失禁

    左踝腫脹

    課程和處理︰

    他被保持intubated,肺的功能改進。

    Extubation被在1/16上執行,他被轉

    更進一步的管理的矯形外科的病房。

    實驗室

    放射學︰

    CT(xx / 01/15) : 沒有對比的末端

    1.粉碎calcaneal Fx。 其他腳共同不能好

    在這項研究過程中評價。

    2.左腳腫脹。

    3.s/p transpedicle 儀器固定

    4.多線的Fx。 用1/3的直徑的壓縮排隊在L1裡

    脊柱運河。

    卸地位︰

    改進並且轉移。

    建議和藥物︰

    為倍數的更進一步的管理換乘到矯形外科的病房

    裂縫。

    祝~~~~~你~~~~~好~~~~~運~~~~~

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