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鳥蛋☆ 發問時間: 社會與文化語言 · 7 年前

急急急~~幫我翻譯一下醫學內容~~20點

Chief complaint:

For 4th course of chemotherapy with HDFL and CDDP

Present illness

This 53y/o patient was acase of*.Breast cancer , left post modified radical mastectomy(1998.4),pT2NOMO,stageII ER(+),PR(-)Her-2(++)with bone metastasis s/p biphosphonate,ascending-colon,right orbital region and liver etastasis,chemotherapy with regimen of 9 courses of CMF(1998.5-1998.10),Vinorelbine/HDFL(2003.4),4 courses of AC(2003.8.4,2003.8.26,2003.9.16,2002.10.8) and palliative radiotherapy(2003.4)with recurrence ER:+ S/P. Femarra,Aromasin,Phyxol+Gemzar,Endoxan+Xeloda,,Farlutal and tri-weekly LipoDox.She was recieved regular follow up at our HEM OPD.Abdominal MRI for regular follow up revealed Multiple(number: at least=7)newly developed nodules on right hepatic lobe are noted. As compared with prior MRI study on 20120827, these hepatic nodules show INCREASE in size and number. She underwent chemotherapy with oral Etoposide(Vepesid) and Tamoxifen (nolvadex) at HEM OPD from Sep 2012 to Feb 2012.Abdomoninal MRI on 20130129 showed multiple metastases on both hepatic lobes show INCREASE in size and number. Therefore, She was admitted for scheduled chemotherapy.

Past history:

*.Denied the Hx of hypertension, DM, or other systemic diseases.

*.Denied the HX of other operation

Personal history:

*.No habit of cigarette smoking or alcohol drinking

Family history:

Family history is nothing in particular

Allergy history:

NKA

Drug resistance

None

Psychosocial Assessment:

Review of systems:

Positive finding : mild fatigue , mild pain over the right supra orbitol region.

Negative finding : no nausea , no weight loss , no chills , no night sweating , no hemoptysis , no epistaxis , no chest tightness , no chest pail , no abdominal pain , no anorexia , no constipation , no diarrhea , no hematemesis , no hematochezia , no melena , no dysuria , no oligouria , no midnight pain , no post-prandial pain , no hungry pain .

Physical examinations:

已更新項目:

Vital signs: BT:36.5℃ BP:122/84mmHg PR:73/min RR:18/min

General appearance:A moderate-developed and moderate-nourshed male.lying on bed with generally fine looking appearance,without cardiopulmonary embarrassment.

Conscious : aleart Mentality : intact to JOMAC

Skin : Petechiae or ecchymosis(一),rash(

2 個已更新項目:

bedsore(一),normal skin turgur

HEENT:Conj:pale(一),sclera:icteric(一),pupils:iscoricL/R +/+ 2.0/2.0mm

Pigmentation on frontal region

Neck : supple,jugular veim engorgement(一),2cm above Louiss angle at 45*,carotid brouits(一),LAP(一),Goiter(一)

Chest : symmetrical&free expansion,clear breath sound,wheezing

3 個已更新項目:

rales(一)

Heart : regular heart beat , PMI at 5th ICS icm lateral LMCL , no murmur , no heave , no thrill , no s3/s4

Abdomen : soft and falt , normoactive bowel sound , built(一) , L/S: impalpable , shifting dullress(一),Murphy•s sign(一) , tenderness(一) , rebounding pain(一) , succusion splasn(一)

Back :

1 個解答

評分
  • 7 年前
    最佳解答

    主訴:

    對於第4個療程的化療與HDFL和CDDP

    現病史

    53Y/ O型病人左側立柱*乳腺癌acase,改良根治術(1998.4),pT2NOMO,stageII ER(+),PR( - ),HER-2(++)與骨轉移的S / P二膦酸鹽,升,結腸癌,右眼眶地區和肝etastasis,化療方案的9門課程的CMF(1998.5-1998.10),長春瑞濱/ HDFL(2003.4),4個療程的AC(2003.8.4,2003.8.26,2003.9.16,2002.10。 8)和姑息性放療復發ER(2003.4):+ S/ P阿諾Femarra,Phyxol+吉西他濱,環磷酰胺+希羅達,Farlutal每週三LipoDox.She的是:收到定期跟進我們的HEM OPD.Abdominal的MRI定期隨訪發現多(編號:至少= 7)新開發的結節肝右後葉上都注意到。相比與以前的MRI研究20120827,這些肝結節的大小和數量的增加。她接受化療與口服依托泊苷(凡畢士)和他莫昔芬(NOLVADEX)從2012年9月至2月2012.Abdomoninal MRI20130129下擺門診顯示多個轉移兩個肝葉顯示在規模和數量的增加。因此,她被送往預定的化療。

    既往史:

    *拒絕HX高血壓,糖尿病,或其他全身性疾病。

    *拒絕其他操作HX

    個人史:

    *吸煙或飲酒習慣。

    家族史:

    家族病史是沒什麼特別的

    過敏史:

    NKA

    耐藥性

    心理評估:

    系統回顧:

    正發現:輕度疲勞,輕度疼痛在右超orbitol的地區。

    陰性結果:無噁心,無消瘦,無畏寒,無盜汗,無咯血,無鼻衄,無胸悶,沒有胸部桶,無腹痛,不厭食,不便秘,無腹瀉,無嘔血,無便血,無黑便,無尿痛,沒有oligouria,沒有午夜痛,沒有餐後疼痛,沒有飢餓的痛苦。

    體格檢查:生命體徵:BT:36.5℃BP:122/84mmHg PR:RR73/min18/min

    整體外觀:在床上適度發達國家和中等nourshed的male.lying的,與一般精緻的外觀,無心肺尷尬。

    自覺:aleart心態:JOMAC原封不動地

    皮膚:皮疹瘀點或瘀斑(一),(褥瘡(一),正常皮膚turgur

    HEENT:連詞:面色蒼白(一),鞏膜黃疸(一),學生:iscoricL/ R+/+2.0/2.0mm

    額葉區域的色素沉著

    頸部:柔順,頸veim的怒張(一),在45 Louiss角上方2cm*,頸brouits(一),LAP(一),“甲狀腺腫(一)

    胸圍:對稱與自由伸縮,清晰的呼吸聲,喘息

    羅音(一)

    心臟:正常心臟的跳動,採購經理人指數5 ICS ICM橫向LMCL的,沒有雜音,沒有起伏,沒有快感,沒有S3/S4

    腹部:軟和鋼構,normoactive的腸鳴音,內置(一),L / S:難以捉摸,移dullress(一),墨菲氏徵(一),(一)壓痛,反跳痛(一),succusion splasn(一)

    返回:

    參考資料: google翻譯
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