幫我翻譯ADMISSION NOTE謝謝

ADMISSION NOTE

Chief Complaint:

RLQ pain for 10 years.

Pressent Illness:

This 32y/o female suffered from intermittent RLQ pain for 10 years.

It has aggrevated recent 3 days and she came to our OPD where appendicitis was impressed.

She was than admitted for surgical intervention and further management.

Past, Personal and Family History:

1.Cardiovascular disease: denied

2.Hypertension: denied

3.Pulmonary disease: denied

4.Gastroenterological disease: denied

5.Liver disease: denied

6.Renal disease: denied

7.D.M. or Endocrinopathy: denied

8.Cigarette smoking or Alcohol drinking: denied

9.Drug allergy: Yes (Drug );No

10.Others: denied

Physical Examination:

General Appearance: NP

Vital Signs: BP 112/62 mmHg, PR 81/min,RR20/min

Development: NP

Nutrition: NP

Mentality: NP

Cooperation: NP

Head:

Conjunctiva: NP

Sclera: NP

Pupil: NP

Light Reflex: NP

E.N.T. : NP

Neck: supple

Thyroid: no goiter

Lymph Node: no LAP

Thorax:

Ches Wall: symmetric expansion

Breast: NP

Lung: B.S.: clear

Heart: RHB

Abdomen: Soft

Shape: flat

Scar: NP

Tenderness:RLQ pain

Palpable Mass: NP

Liver: NP

Kidney: NP

Spleen: NP

Others: NP

Extremities: freely morable

Impressions:

Appendicitis

POST OP NOTE

Post op day

Dx:Appendicitis

OP:Laparoscopic Appendectomy

2005/02/02 10:30 主治醫師回診

S: wound pain

O: weak alart BP 110/70mmHg TPR:37.82.18

Abdomen c gauze cover. JP redness discharge 30c.c.

Distension(±)

Stool(-)

P:1.wound care qd

2.monitoring the amount, color of JP

3.encourage ambulation

2005/02/03 11:00 主治醫師回診

S: no c/o

O: w’d clear JP

flatus(+)

no stool passage

bowel sound(+)

P:1.wound care

2.remove JP

3.encourage ambulation

Appendicitis Clinical Path Pre-OP Orders

1.On TPR & BP qid

2.NPO

3.Check:

EKG if>40y/o

CXR

KUB

CBC/DC,PT,APPT

BUN

ALT,AST,blood glucose,amylase

Na,K,Cl

urinalysis

4.Sign OP and anesthesia consent

5.Prepare skin of public region at OR

6.Consult anesthesiologist

7.Medications(兒童劑量依體重計算)

a.D5W 500ml iv drip

b.Cefazolin 1 gm send to OR

c.Gentamicin 80 mg send to OR

3 個解答

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  • 1 0 年前
    最佳解答

    我將答案寄到妳信箱了

  • 6 年前

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  • 1 0 年前

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