o******h
发帖数: 198 | 1 即日起 大家有空发一些匿名的病历讨论吧 熟悉一下病历书写和缩写吧
有不懂的可以提问 有工作经验的同学路过可以帮助回答
回帖的同学 第一部分请写你的问题， 第二部分请写你知道的答案 谢谢!
不会念医学单词的可以查这个 没有声音的 按允许pop up插件即可
http://www.merckmanuals.com/home/resources/pronunciations/index
xxx year old F with a pmh significant for dementia,asthma, dvt, pe in 2011,
htn, osteoporosis, rectal bleeding, new dvt rt. Leg 03/31 restarted on
Coumadin and lovenox, non verbal sent from NHF on 4/3 for drop in H/H 7/23.
On arrival V/S: 153/51, 74, 20, 99.4 and o2 100% on ra. Awake and non verbal
, neuro motor and sensory intact, bilat leg edema. Found with wbc 26.3/8.7,
RBC-3.35, INR 1.1, PT 10.8, BUN 24, stool for ob neg. CXR No focal pna. Pt
received 1 unit PRBC. GI consult pending. Coumadin on hold, Echo, o2 2L nc,
CBC Q8hrs. Pt is awake non verbal.
4/5- Rt parotid lesion, which has increased in size compared iwht the prior
exam. Oropharyngeal airway narrowing which now measures 6 compared to 9 in
prior exam. New RLE DVT involving femoral vein, worsening anemia/prior GI
bleed. FOBT-neg, CT abd/pelvis no retroperitoneal or pelvic hematoma. Plan-
start anticoagulation Heparin, monitor H/H closely s/p vascular surgery
consult, not a candidate for thrombolysis, not for IVC filter placement, PTT
, CBC monitoring,
4-6 V/S 138/60 HR 76 RR 20 Temp 98.5 more alert. Tenderness and redness
along the medical part of rt thigh improving. Cont. IB Heparin, H/H no sig
change. FOBT 2 sets are neg. CT abd w/o contrast to r/o retro peritoneal
bleed.
4/7 CT of head and neck: no acurte intracreanial abnormality, dominant rt
parotid lesion partially affecting the orophary ngeal airway unchanged from
recent prior study although progressive from a more remote study. stable. | o******h
发帖数: 198 | 2 请问谁知道 pe in 2011是什么意思？
请问谁知道 No focal pna是什么意思？
————————————————————————————————
phm-primary history
H/H: Hb and Ht
CXR -chest x-ray
abd -abdominal | y**m
发帖数: 1049 | 3 PE - pulmonary embolism
PNA - pneumonia
【在 o******h 的大作中提到】
: 请问谁知道 pe in 2011是什么意思？
: 请问谁知道 No focal pna是什么意思？
: ————————————————————————————————
: phm-primary history
: H/H: Hb and Ht
: CXR -chest x-ray
: abd -abdominal
| s*******y
发帖数: 1739 | 4 既然是case study， 你目的是什么？只是单纯学缩写和英文，还是学习治疗思路，如
果是后者，你就应该把这个case说得全面一些，这个case病人多大年纪了，用的什么药
在nursing home， 还有lab也写得不清不楚，WBC 是26.3/8.7是什么项目，这个很关键
，因为你这个case的主诉是droppedH/H，而你的case说得hgb 是8.7吗，只是我个人意
见， 感觉这个case说的不明不白，不知怎么case study |
|
