蛋蛋 發問時間: 社會與文化語言 · 8 年前

幫忙翻譯一下病歷 20點!! (請不要給我翻譯機的翻譯)

Chief Complaint:

Abdomen painful sensation, distension, multiple abrasion wound of abdomen and Lt. forearm past car accident for two days.

Present Illness:

According to this patient's statement, he was robust in the past. Unfortunately, he suffered from car accident and collided by a car over abdomen region on Oct 3 95'. then he was sent to XX醫院 and received conservative treatment. Today, those symptons became deteriorated and he was transfered to our ER and admitted for further evaluation and managements.

Past, Personal and Family History:Nothing particular.

Physical Examination:

General Appearance:Ill-looking. Development:MD.

Nourishment:MN.

Mentality:Clear. Skin:Multiple abrasion wound of abdomen.

Head and its organs: and Lt. forearm.

Conjuntiva:No anemia. Sclera:No icteric scleric change.

Neck:Supple. Lymph Nodes:No Lymphadenopathy.

Chest:Symmetrical expansion with free movements.

Heart:Regular heart beat.

No murmur or thrill.

Lungs:Clear breathing sounds. Bil.

No rales or wheezing sounds.

Abdimen:Abdomen painful sensation with rebounding pain and distension.

Liver:No hepatomegaly.

Others:Abrasion wound of abeomen.

Extremities:No pitting edema.

Reflexes:No pathological reflexs.

Others:X-ray revealed subphrenic free air.

BP:100/60 mmHg.

Impression:Blunt abdomen injury with

perforation of hollow organs.

Signature:Dr. 陳XX

2 個解答

評分
  • 8 年前
    最佳解答

    Chief Complaint:主訴:

    Abdomen painful sensation, distension, multiple abrasion wound of abdomen and Lt. forearm past car accident for two days.

    病人常覺腹疼腹脹,兩天前發生車禍造成腹部及左前臂有多處擦傷.

    Present illness: 症狀:

    According to this patient's statement, he was robust in the past. Unfortunately, he suffered from car accident and collided by a car over abdomen region on Oct 3 95'. then he was sent to XX醫院 and received conservative treatment. Today, those symptons became deteriorated and he was transfered to our ER and admitted for further evaluation and managements.

    病人自訴,身體向來健壯,不幸於1995年十月33日發生車禍意外,一輛車撞上他的腹部,當時被送到 XX醫院接受保守性治療.今日因種種症狀惡化而轉至我院急診室做觀察.

    Past, Personal and Family History:Nothing particular.

    病史:無特殊病史紀錄.

    Physical Examination:體格檢查:

    General Appearance:Ill-looking. 外觀:病態

    Development:MD.

    Nourishment:MN.

    Mentality:Clear. 精神狀況:正常.

    Skin:Multiple abrasion wound of abdomenand Lt. forearm. .

    皮膚:腹部及左前臂有多處擦傷

    Head and its organs:

    Conjuntiva:No anemia. 眼結膜:無貧血.

    Sclera:No icteric scleric change. 鞏膜:無黃疸變化.

    Neck:Supple. 頸:正常

    Lymph Nodes:No Lymphadenopathy. 淋巴結:正常

    Chest:Symmetrical expansion with free movements.

    胸:正常

    Heart:Regular heart beat. No murmur or thrill.

    心臟:心跳正常,無心雜音或震顫音.

    Lungs:Clear breathing sounds. Bil. No rales or wheezing sounds. 肺:正常呼吸聲,無鑼音或喘息.

    Abdimen:Abdomen painful sensation with rebounding pain and distension.腹部:腹部反彈觸痛及腹脹.

    Liver:No hepatomegaly. 肝:無肝腫大.

    Others:Abrasion wound of abeomen. 其他:腹部擦傷.

    Extremities:No pitting edema. 四肢:無水腫.

    Reflexes:No pathological reflexs. 反射:無病理反射.

    Others:X-ray revealed subphrenic free air. 胸部X光顯示膈下有氣體.

    BP:100/60 mmHg.血壓:100/60

    Impression:Blunt abdomen injury with perforation of hollow organs.

    Signature:Dr. 陳XX

    初步評估:挫傷及內臟穿刺傷.

  • 8 年前

    長官 Complaint:腹部感覺痛苦,擴張,腹部和上尉前臂過去兩天車禍多個磨傷。

    目前 Illness:據這位病人的聲明,他是魯棒在過去。不幸的是,他遭受車禍,被一輛車相撞腹部地區上空,在 95 年 10 月 3 日 '。然後他被送到 XX醫院,並接受保守治療。今天,這些版塊成為惡化,他被調到我們 ER 和承認進一步評價和管理。

    過去,個人及家庭 History:Nothing 特別。

    物理 Examination:一般 Appearance:Ill 找。Development:MD。Nourishment:MN。Mentality:Clear。Skin:Multiple 磨損的腹部的傷口。頭及 organs: 上尉前臂。Conjuntiva:No 貧血。Sclera:No 黃疸型 scleric 變化。Neck:Supple。淋巴 Nodes:No 淋巴結腫大。Chest:Symmetrical 膨脹的自由流動。Heart:Regular 的心跳。無雜音或興奮。Lungs:Clear 呼吸的聲音。Bil。無羅音或喘鳴聲。Abdimen:Abdomen 與反彈的疼痛和擴張的痛苦感覺。Liver:No 肝腫大。Others:Abrasion 的 abeomen 的傷口。Extremities:No 點蝕水腫。Reflexes:No 病理 reflexs。Others:X 射線透露膈下自由的空氣。BP:100/60 毫米汞柱。

    Impression:Blunt 腹部損傷穿孔的中空器官。Signature:Dr。陳XX

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