常見診斷之病歷翻譯 (急)

According to the statements of the patiens’s caregiver and the old medical record. this is 77year-old male with a history of HTN and COPD, L-Spine DJD change under medical control. He performed well daily life before and was able to walk well.

In this early morning. he wakes up to the toilet but sudden onset of weakness occurs And the patient falls down .resulted in multiple abrasion wound over the left side.Frontal area and lower limbs. There’s no loss of consciousness but he can not stand up anymore. He wants to crawl to the phone but he cant not do it. so he sleep on the ground until sunrise. Then he sent to ER for help.

At arrival the patlent presents with acute ill-looking and PE reveals alert and
oriented Consciousness bilateral normal pupil size. Normal light reflex and normal EOM without nystagmus.There’s left side hemiparesis. In addition. wheezing breathing sound is are agministered. brain CT is performed and it shows no obvious large infarction or ICH The CXR shows no caediomegaly with bilayeral lung incrased infiltration and no pneumonia patch. The blood exam reveals normal sugalr level. Normal renal function and normal liver function. High elevated CK level is noted with normal CKMB. Level. The EKG shows sinus rhythm without ischemic change. Aspirin and dipyridamole are administered and then for fureher managent .he is admitted.