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? 發問時間: 社會與文化語言 · 1 0 年前

理學檢查報告翻譯,請幫幫我~急送20點

理學檢查

General appearance:

Acute ill looking

Consciousness:

Clear,E4V5M6

Heent:

Sclera:not icteric

Conjunctiva:not pale

Neck:

Supple

No jugular vein engorgement

No lymphadenopathy

Chest:

Breath pattern:smoth,bilateral symmetric expansion

Brerthing sound:bilateral clear and symmetric bteathing sound

Wheezing:no Wheezing

Heapt:

Regular heart beat without audible murmur

Abdomen:

Soft and flat no superficial vein engorgement

Liver and spleen not palpable

No shifting dullness

No tenderness;no rebounding pain

Nowel sound:normoactive

Back:

No knocking pain over bilateral flank area

Extremities

No joint deformity

Freely movable

No pitting edema

Peripheral pulse:symmetric

Muscle power:full

Gait:small steps

實驗室檢查:

血液20090522生化20090522尿液20090522

WBCCreatinineColorPale yelliw

RBCEstimatedTurbidityClear

HemoglobinALT/GPTSp.Gravity1.007

HematocritCalciumPH7.0

MCVNaLeukocyteNegative

MCHKNitriteNegative

MCHCClProtenNegative

RDWdiphenylhyGlucoseNegative

PlateletsKetoneNegative

SegmentUrobilinogen0.1

LymphocyteBilirubinNegative

MonocyteBloodNegative

EosinophilRBC0

BasophilWBV0

Epith-cell0

臨床臆斷

1 seizure,favor brain metastasis related

2non-small cell kung cancer,adenocarcinoma,stage IV with brain and bone metastasis post radiotherapy and completed 6 cycles of Taxol+Cisplatin since 974/19~97/9/27

3 hypertension

4.hyperlipidemia

處理計畫plan

1.dexan injection for brain netastasis,consider radiation therapy keep dilantin and keppra used

2.keep OPD medication

3.symptomatic treatment

已更新項目:

實驗室檢查那我修改一下

血液20090522

WBC

RBC

Hemoglobin

Hematocrit

MCV

MCH

MCHC

RDW

Platelets

Segment

Lymphocyte

Monocyte

Eosinophil

Basophil

生化20090522

Creatinine

Estimated

ALT/GPT

Calcium

Na

K

Cl

diphenylhy

2 個已更新項目:

尿液20090522

ColorPale yelliw

TurbidityClear

Sp.Gravity1.007

PH7.0

LeukocyteNegative

NitriteNegative

ProtenNegative

GlucoseNegative

KetoneNegative

Urobilinogen0.1

Bilirubin Negative

Blood Negative

RBC 0

WBV 0

Epith-cell 0

2 個解答

評分
  • 1 0 年前
    最佳解答

    理學檢查

    General appearance:一般外觀

    Acute ill looking

    Consciousness:意識

    Clear,E4V5M6清楚,昏迷指數15分

    Heent:頭.眼.耳.鼻.喉

    Sclera:not icterice 鞏膜沒有黃疸

    Conjunctiva:not pale 結膜沒有蒼白

    Neck:頸

    Supple柔軟的

    No jugular vein engorgement沒有頸動脈充血

    No lymphadenopathy沒有淋巴腺病

    Chest:胸

    Breath pattern:smoth,bilateral symmetric expansion

    呼吸型態:平順.兩側的對稱的膨脹

    Brerthing sound:bilateral clear and symmetric bteathing sound

    呼吸聲音:兩側清楚對稱呼吸音

    Wheezing:no Wheezing沒有Wheezing聲

    Heart:心臟

    Regular heart beat without audible murmur 正常心跳沒有心雜音

    Abdomen:腹部

    Soft and flat no superficial vein engorgement柔軟平坦沒有靜脈充血

    Liver and spleen not palpable肝臟和脾臟沒有腫塊

    No shifting dullness沒有移動性濁音

    No tenderness;no rebounding pain沒有觸痛及反彈痛

    Nowel sound:normoactive

    Back:背

    No knocking pain over bilateral flank area沒有敲打後疼痛至兩側協腹部

    Extremities四肢

    No joint deformity沒有關節變形

    Freely movable自由移動

    No pitting edema沒有水腫

    Peripheral pulse:symmetric 末梢的脈搏對稱

    Muscle power:full肌肉有力

    Gait:small steps步態小步伐

    實驗室檢查:臨床臆斷

    1 seizure,favor brain metastasis related癲癇與癌細胞腦部轉移相關

    2non-small cell kung cancer,adenocarcinoma,stage IV with brain and bone metastasis post radiotherapy and completed 6 cycles of Taxol+Cisplatin since 974/19~97/9/27

    非小細胞kung癌,第四期腦與骨轉移,已經經放射線治療及化學治療六循環後

    3 hypertension高血壓

    4.hyperlipidemia高脂血症

    處理計畫plan

    1.dexan injection for brain metastasis,consider radiation therapy keep dilantin and keppra used

    Dexan注射治療癌細胞的轉移到腦,考慮持續用放射線持續療法

    2.keep OPD medication持續門診藥物治療

    3.symptomatic treatment 症狀治療

    •2009-06-04 23:56:01 補充

    超過字數限制分兩次回答

    2009-06-07 09:53:37 補充:

    貼不進

    請到布的狂想曲留言

    參考資料: 華杏醫學辭典, 字典
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  • mcatee
    Lv 4
    3 年前

    Neck Vein Engorgement

    • Commenter avatar登入以對解答發表意見
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