匿名使用者
匿名使用者 發問時間: 社會與文化語言 · 6 年前

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 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

評分
  • 6 年前
    最佳解答

    過去病史(病史)

    瑞秋沒有什麼大的醫療問題(無哮喘,糖尿病,心臟疾病,頻繁的感染史,早產,和鐮狀細胞),但出生後兩次因呼吸系統的問題被帶到急診科。她被發現在用沙丁胺醇PRN治療時與之前,有右下葉喘息的問題與呼吸系統疾病。

    社會史(社會史)

    1.飲食 :用奶瓶餵養ISOMIL。每天6瓶,每瓶6盎司。

    2.睡眠:睡在她自己的嬰兒床。

    3.排泄:不腹瀉,不便秘。每天一到兩次BM。

    4.活動:活動水平是正常的。與她玩的時候開心地笑。警惕,沒有過度哭鬧或挑食行為。未發現明顯減少活動量。

    理學檢查(體檢)

    1.重要體徵:脈搏136 /溫度97.7 / RESP 40

    2重量: 14磅1盎司( 6.390千克) - 第12個百分

    3.身高: 2 ' 41 '' ( 0.620米) ,第25個百分

    4.頭周長42.5厘米 - 50個百分

    5一般外觀:警報,無痛苦,合作

    6.耳朵: R't TM正常,灰色,光亮,沒有流體。

    L't TM正常,灰眩,沒有流體。

    7.鼻:粉紅色,防潮,無滲出物。

    8. 口咽:粉紅色,防潮,無滲出物。

    9. 頸部:柔順且無淋巴結腫大

    10.肺:良好的空氣流動,在右下葉有很小間歇呼氣哮鳴音

    。良好的A / E和正常率。無回縮。

    11.心臟:正常率和節奏沒有任何雜音,點擊,或急馳。

    臨床診斷(印象)

    毛細支氣管炎

    處理計畫(管理計劃)

    1.跟進毛細支氣管炎與改善症狀。

    2.繼續TX每4小時服3天,直到用完的藥物。3. 從在病毒餐廳嚴格獲取病毒感染討論預防措施納秒。

    4.一個星期後RTC(回診),並安排她的下個VACC的日程。

    簽名:林/張

    (住院醫師) (參加醫師)

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