幫忙翻譯病例成中文(20點)

過去病史(Illness History)   Rachel dose not have any major medical problems (no asthma, DM, he art disease, history of frequent infections, premature, and sickle cel l) but was brought to ED twice for respirator problems after birth. Sh e was found with RLL wheezing problems with respiratory illness before and... 顯示更多 過去病史(Illness History)
  Rachel dose not have any major medical problems (no asthma, DM, he
art disease, history of frequent infections, premature, and sickle cel
l) but was brought to ED twice for respirator problems after birth. Sh
e was found with RLL wheezing problems with respiratory illness before
and treated with Albuterol prn.
社會史(Social History)
1.Eating:Bottle fed with Isomil. 6 bottles per days, 6 ounces per bo
ttle.
2.Sleep:Sleep in crib on her own.
3.Elimination:No diarrhea and no constipation. Once to twice BM per
day.
4.Activity:Activity level is normal. Smile happily when playing with
her. Alert, no excessive crying or fussy behavior. No obvious decrea
sing activity level observed in this illness visit.
理學檢查(Physical Exam)
1.Vital signs:Pulse 136 / Temp 97.7 / Resp 40
2.Weight:14 lbs 1 oz (6.390 kg)—12th percentile
3.Height:2' 41'' (0.620 m)—25th percentile
4.Head Circumference:42.5 cm—50th percentile
5.General appearance: Alert, no distress, cooperation
6.Ears:R't TM—normal, gray, shining and no fluid.
L't TM—normal, gray shining and no fluid.
7.Nose:pink and moisture, no exudates.
8.Oropharynx:pink and moisture, no exudates.
9.Neck:supple and no adenopathy
10.Lung:good air movement, minimal intermittent expiratory wheeze on
the RLL. Good a/e and normal rate. No retraction.
11.Heart:regular rate and rhythm and no murmurs, clicks, or gallops.
臨床診斷(Impression)
Bronchiolitis
處理計畫(Plan of Management)
1.Follow up for bronchiolitis with improvement of symptoms.
2.Continue tx every 4 hours for 3 days until run out of medications.
3.Discuss preventions from getting viral infections during viral seaso
ns.
4.RTC (Return to clinic) after one week and schedule for her next vacc
ination.


Signature:   Lin  /      Chang   
(Resident)  (Attending Physicain)
1 個解答 1