綾香 發問時間: 社會與文化語言 · 4 年前

求求好心人告訴我這段醫術寫甚麼?

On Herbal Medication usage/Nutritional supplements:Denied

Past Hospitalization,Operations,and Trauma History:

Operation history:雙眼眼袋手術近視雷射手術

Allergies to food and drugs:Not known prior to this admission

Personal History:

Education:碩士 Marital Status:單身

Occupation:其他 Stress situation:生活忙碌

Alcohol:Not

Smoking:Not

Betel Nuts:Not

Recent travel history:None

Family History:

Father:Healthy

Mother:Healthy

Sibling:Healthy

Children:None

Denied of Recent hospital ization history in household members of relatives

1. General:Fever(-),Chills(-),Fatigue(-),Loss of appetite(-),Night sweating(-),Weight record change recently(-)

2. Head, Eye,ENT,Neck:Headache(-),Blurred vision(-),Vertigo(-),Sore throat(-),NSD with CHR(+),Oral ulcers(-),Neck stiffness(-),Enlarged lymphnodees(-).

3. Respiratory:Cough(-),Sputum(-),Henoptysis(-),Chest pain(-),Dyspnea(-),Wheezing(-).

4. Cardiovascular:Precordial pain(-),Dyspnea on exertion(-),Orthopnea(-),Paroxysmal Nocturnal Dysnpnea(-),Palpitation(-).

5. Gastro-IntestinalNausea(-),Vomiting(-),Jaundice(-),Abdominal pain(-),Blood in stool(-),Change in bowel habits(-),Constipation(-),Diarrhea(-).

6. Genito-Urinary:

Polyuria(-),Oliguria(-),Dysuria(-),Frequency(-),Urgency(-),Nocturia(-),Hematuria(-),Incontinence(-).

7. Musculo-Skletal:

Back pain(-),Arthragia(-),Myalgia(-).

8. Skin,Hair Nail:

Rash(-),Pruritus(-),Lumps(-).

9. Neurology:

Syncope: (-),Dizziness(-),Involuntary movement(-),Focal weakness(-),Numbness(-).

10. Psychiatry:

Delirium(-)

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1 個解答

評分
  • 4 年前
    最佳解答

    On Herbal Medication usage使用草本藥物/Nutritional supplements營養補充食品: Denied否認

    Past Hospitalization住院,Operations手術,and Trauma History和創傷經歷:

    Operation history手術經歷: 雙眼眼袋手術近視雷射手術

    Allergies to food and drugs食品和藥物過敏: Not known prior to this admission在此之前未知

    Personal History個人經歷:

    Education教育:碩士

    Marital Status婚姻狀況: 單身

    Occupation職業: 其他

    Stress situation壓力情況: 生活忙碌

    Alcohol喝酒: Not 無

    Smoking抽菸: Not無

    Betel Nuts檳榔: Not無

    Recent travel history近期的旅行史: None無

    Family History家庭病史:

    Father父親: Healthy健康

    Mother母親: Healthy健康

    Sibling兄弟姊妹: Healthy健康

    Children孩童: None無

    Denied of Recent hospital ization history in household members of relatives

    否認家庭成員的近期住院史

    1. General一般:

    Fever發燒(-),Chills寒顫(-),Fatigue疲勞(-),Loss of appetite食慾不振(-),Night sweating夜間流汗(-),Weight record change recently近期體重改變(-)

    2. Head頭部, Eye眼睛,ENT耳鼻喉,Neck脖子:

    Headache頭痛(-),Blurred vision視力模糊(-),Vertigo眩暈(-),Sore throat喉嚨痛(-),NSD with CHR慢性鼻炎(+),Oral ulcers口腔潰爛(-),Neck stiffness頸部僵硬(-),Enlarged lymphnodees擴大淋巴結(-).

    3. Respiratory呼吸系統:

    Cough咳嗽(-),Sputum痰(-),Henoptysis咳血(-),Chest pain胸部疼痛(-),Dyspnea呼吸不順暢(-),Wheezing哮喘(-).

    4. Cardiovascular心血管疾病:

    Precordial pain心前區痛(-),Dyspnea on exertion呼吸困難(-),Orthopnea端坐呼吸(-),Paroxysmal Nocturnal Dysnpnea夜間陣發性呼吸困難(-),Palpitation心悸(-).

    5. Gastro-Intestinal胃-腸:

    Nausea噁心(-),Vomiting嘔吐(-),Jaundice黃疸(-),Abdominal pain腹痛(-),Blood in stool血糞便(-),Change in bowel habits改變排便習慣(-),Constipation便秘(-),Diarrhea腹瀉(-).

    6. Genito-Urinary泌尿生殖系統:

    Polyuria多尿(-),Oliguria少尿(-),Dysuria排尿困難(-),Frequency頻繁(-),Urgency尿急(-),Nocturia夜間排尿(-),Hematuria血尿(-),Incontinence尿失禁(-).

    7. Musculo-Skletal肌肉骨骼:

    Back pain背疼痛(-),Arthragia關節痛(-),Myalgia肌肉疼痛(-).

    8. Skin皮膚,Hair頭髮 Nail指夾:

    Rash疹子(-),Pruritus瘙癢症(-),Lumps腫塊(-).

    9. Neurology神經病學:

    Syncope昏厥: (-),Dizziness頭暈(-),Involuntary movement非意志晃動(-),Focal weakness注意力散漫(-),Numbness麻木(-).

    10. 精神病學:

    譫妄(意識混亂,急性精神病)(-)

    ______________________________________

    歡迎指教~

    參考資料: www.dict.tw
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