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病历翻译:中译英-脑梗塞

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门诊诊断:急性脑血管意外:脑梗塞?

Outpatient service diagnosis:Acute accident of blood vessel of brain: cerebral infarction?

入院诊断:头痛晕厥待查:脑血管意外?颈椎病?血管性头痛?

Diagnosis upon hospitalization:Headache and faint to be checked: accident of blood vessel of brain? cervical spondylosis? Vascular headache?

出院诊断:短暂性脑缺血发作: 多发性腔隙性梗塞,脊椎病,腰椎病,尿路感染,呼吸道感染,老年性便秘

Discharge diagnosis:Attack by temporary cerebral ischemia   Multiple Lacunar Cerebral Infarction, cervical spondylosis, lumbar vertebra disease, infection of urinary tract; J respiratory tract infection, constipation of aged people

病程与治疗结果(注明手术名称、日期、输血及抢救情况)

Sickness course and treatment result (indicating operation name, operation date, blood transfusion and rescue situation )

患者入院后为明确诊断,予完善相关检查,并予监测血压、吸氧;因急查头颅CT明确脑梗塞,遂予银杏达莫活血化瘀抗血小板凝集,西比灵减轻脑血管痉挛,恩经复(鼠神经生长因子),单唾液酸四己糖神经节苷酯钠营养脑神经;因尿常规提示尿路感染,结合临床体征后加予左氯氟沙星抗感染:后因患者外出散步时受凉,出观咽痛,流涕,千咳,遂予胸腺肽增加免疫力,百服宁(酚麻美敏片)对症改善卡他症状;另予英沙比利促肠道蠕动,肠泰合剂调节肠道功能,通泰(葡苷聚糖),开寒露润肠通便,改善老年性便秘:囡发现颈动脉多发性斑块,遂予立管妥稳定斑块治疗:治疗中,患者曾于入院次日再次突发晕摩,意识短暂丧失数秒后恢复,经治疗患者后未再出现头痛晕厥,肩颈部疼痛基本消失,卡他症状消失,尿频尿急消矢。

After hospitalized, relevant examinations are further made to the patient to clarify the diagnosis, and blood pressure measurement, oxygen absorption is provided. As cerebral infarction is determined via head CT, Ginkgo Leaf Extract and Diphyridamole Injection is applied to reduce stasis and improve blood circulation against agglutination of blood platelets; and Flunarizine to reduce spasm of blood vessel of brain; NOBEX (growth factor of rat nerve); GM1,Monosialotetrahexosylganglioside to provide nutrition to nerves. The routine urination examination prompts infection of urinary tract, so combined with clinical physical features, levofloxacin is provided for anti-infection. Later, the patient got cold when walking outside, she suffered angina, nasal mucus, dry cough, then thymopeptide is provided for increasing immunity. Bufferin Cold (Paracetamol) is used to improve Coryza symptom. Mosapride is used to impulse enterokinesia of intestinal tract; Changtai Mixture is used to adjust function of intestinal tract; Tongtai (Glucomannan) and Glycerine Enema are used to lubricate the intestines and ease constipation. Since multiple plaques are found at neck artery, Lipitor is used for plaque treatment. During treatment, the patient suffered sudden faint on the next day after hospitalized, and lost consciousness for several seconds. After treatment, no headache and faint appear again. The pain at neck and shoulder disappear basically. The Coryza symptom disappears,    Frequent and urgent urination disappears.

合并症

Complication

出院时情况(症状与体征)

Situation at discharge (symptom and physical features)

患者目前无不适主诉,夜眠好,胃纳好,二便通畅,查体:T:37℃,血压l20/170 mmHg,神清,气平,瞳孔等大等圆,对光反射正常,无眼震,颈软,左侧颈动脉课闻及血管杂音,肩颈部压痛(+).抬臂试验(一),口角略右甭:伸舌尚居中,两肺呼吸音清,来闻及罗音心率:73BPM,律齐,腹平软,无压痛,未及包块,肠鸣音3次/分钟,移动性浊音(一),四肢肌张力正常,四肢肌力V对称,霍夫曼征(…),巴氏征、克氏征、欧苯海姆征、高登征约阴性。

Right now, the patient has no obvious uncomfortable complaint. Sleep well, eat well, smooth urination and faeces. Physical check: T:37°C, BP: 120/70mmHg, clear minded, smooth respiration, equal round and big pupils, normal reflection to light; no limited vibration, bland neck. Noise in blood vessels can be heard at the left neck artery. Tenderness at neck and shoulder (-); arm lifting test (-);corner of mouth a little inclined to right. The tongue locates in the center when extended. Clear respiratory sound of both lungs; no rale is heard. HR: 738 PM; with good rhythm, bland and soft abdomen; no tenderness; no mass is touched. Peristaltic sound 3 times/min.; mobile sonant (-); normal muscle tension of four limbs; muscle force of four limbs V°; symmetrical; negative for Hoffman sign (-);Babbitt sign; Kernig’s sign; Oppenheim sign; Gordon’s sign

出院医疗与康复指导

Treatment after discharge and recovery instructions

继续于医院积极治疗,避免情绪激动,避免提领重物,注意保暖及个人清洁卫生。

Continue to receive active treatment in Hospital, avoid spirit excitement, avoid lifting heavy objects, pay attention to personal hygiene and wear enough clothes to keep warm.

治疗结果:好转

Treatment result:Turned better

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