医院交班记录(英文版)
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xx male 52y
Primary diagnosis:type 2 diabetes mellitus
Chief complaint: detection of glucose high of more than 10 years, polydipsia and polyuria, lack of power for more than half year
Auxiliary examination:a normal electrocardiogram. Glycated['ɡlaikei t]
hemoglobin[,hi?m??'ɡl??b?n]: 9%. routine urinalysis 15mmol/L.FBG(fasting blood-glucose):glucose+++(plus sign). Ketone bodies and urine protein are negative ( August 25th) Treatment:
1 control diet, adequate exercise, monitoring of blood glucose
2 to improve the relevant examination in the assessment of pancreatic endocrine function and complications of diabetes
3 according to the levels of blood glucose and check results of adjustment next plan.
xxx, female, 75 y.
Primary diagnosis:severe osteoporosis.
Chief complaint:Body pain for more than one year, aggravated for two months. Hypertension 2 (medium risk group), chronic nephritis.
Auxiliary examination:No
Treatment: Improve the relevant checks;added calcium, vitamin D and bisphosphonates,;calcitonin applications,;symptomatic and supportive treatment,;hygiene education。
xxx,male,24-year-old
Primary diagnosis:Low gonadotropin gonadal dysgenesis低促性腺激素性性腺发育不良
Chief complaint:short penis and scrotum empty for 20 years
Auxiliary examination:No cracking, no beard, pubic hair, armpit hair
Treatment: Improve the relevant checks,;hormone replacement therapy;hygiene education。
xxx female,50 years old
Primary diagnosis:1. Goiter, 2. Rheumatoid arthritis, 3.cerebral vasospasm
Chief complaint:Shoulders back pain persists more than 3 month
Auxiliary examination:No
Treatment: 1 Routine medical care,2 pay attention to rest, detects vital signs; 3 review the blood routine, thyroid function, liver function; 3. Strengthen support treatment; 4. Improve the related auxiliary examination
xxx female 55 y.
Primary diagnosis:Diabetes with peripheral neuropathy
Chief complaint:Thirsty, polydipsia, diuresis for 8 years. With feet numbness for 1 year and muscle weakness for 8 months; Aggravate for 3 months。
Auxiliary examination: no
Treatment: After admission do blood routine、urea routine, what's more do electrolyte inspection to Eliminate ketosis and the possibility of high permeability .
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