請幫幫我非常非常急 醫護英文 chart翻譯

.Chronic renal failure .L-spinal compression fracture S/P with dependent foley tube 家族病史 Denied hereditary disease. PE: .General appearance: Consciousnees GCS:E4V3M6 Appearance ill-looking .Head&its organs: NO sclera icteric,conjunctivae:pale(+) .Neck:Supple,no jugular vein enlargement no Lymphadenopathy no... 顯示更多 .Chronic renal failure
.L-spinal compression fracture S/P with dependent foley tube
家族病史 Denied hereditary disease.
PE:
.General appearance:
Consciousnees GCS:E4V3M6 Appearance ill-looking
.Head&its organs:
NO sclera icteric,conjunctivae:pale(+)
.Neck:Supple,no jugular vein enlargement no Lymphadenopathy no thyroid enlargement4.Chest&lungs:Appearance:normal,Expansion:symmetrical,Breathing sound:clear5.Heart:
Heart beat:regular no heart murmur6.Abdomen:
distension,no rebounding pain no palpable mass hypoactive bowel sound
.Back&spines:
No knocking pain over c-v angle
8.Extremities:
pitting edema:no ROM:free
9.Laboratory deta:
尿液、尿液生化檢驗:
9/8 Apperance:Clear,Nit:1+,Leu:1+(75)Leu/ul,SG:1.009,RBC:10-20,WBC:40-50,
Epith:0.5,Bacteria:2+,Cast 1:-,Crystals 1:-,Uro:-(<1.5)mg/dl,color:Light Yellow,O.B:2+(0.2)mg/dl,Bil:- mg/dl,keto:+/- mg/dl, Glu:2+(150)mg/dl, Pro:3+(300),PH:6.0
血液:
2/20 WBC:7.01 103/ul ,RDW-CV:14.2%,RBC:3.65 106/ul,HGB:10.7g/dl,HCT:30.3%,
MCH:29.3 pg,MCHC:35.3 g/dl,platelet:80.0 103/ul,RDW-SD:43.4 fl,RDW-CV:14.2%,
Lymphocyte:11.3%,Monocyte:3.6%,Eosinophil:2.1%,Basophil:0.0%
生化:
GOT:28U/L,GPT:15U/L,BUN:91.6 mg/dl,Blood Creatinine:46. mg/dl,Sugar:144 mg/dl,Na:127 mEq/L,K:4.2 mEq/L,eGFR:6.69
病毒學:
Influenza A Ag:Negative,Influenza B Ag:Negative
系統評估1.General:
usual weight(-);recent weight changes(-);fever(+);weakness(+);Fatigue(+).
.SKIN:rash(-);eruptions(-);dryness(-);cyanosis(-);jaundice(-);changes in skin,hair,or nails(-):petechiae(-);purpura(-);itching(-).
.HEAD:headache(-)
.EYES:glasses or contact lenses(-);last eye examination(-);glaucoma(-);
Cataracts(-);eyestrain(-);pain(-);diplopia(-);redness(-);lacrimation(-);
Blurring(+).5.EARS:loss hearing(-);discharge(-);tinnitus(-);dizziness(-);pain(-)6.NEURROLOGICAL SYSTEM:Fainting(-);bllackouts(-);seizures(-);paresis/paralysis(-);tingling(-);
Tremors(-);memory loss(-);numbness(-).7.MUSCULOSKELETAL SYSTEM:Bone pain(-);arthralgia(-);myalgia(-);weakn
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