求大家幫我翻譯這段病歷?

2016-01-25 4:06 pm
Percussion-No abnormal findings
Heart:
Regular heart beats with no audible murmurs or gallops heard
Abdomen:Inspection-Distended with no abdominal mass nor visible bowel
Movement seen
Auscultion-active bowel sounds
Palpation-palpable mass of lower abdomen
Percussion-No focal tympany nor dullness
No costovertebral angle knocking tenderness
Rectal and Genitalia:No abnormal findings
Extremities:Freely movable limbs
No pedal edema
Neurological exam:
Cranial nerve:intact
Muscle power:symmetry over4 limbs 5+
Sensation:no paresthesis
Gait:Intermittent claudication(-)
Spnincter funcyion:intact
Initial Laboratory Dateand Images:
None
Comment on initial Laboratory Date and Imges:
None
Initial Diagnosis
1. Left inguinal hernia

回答 (1)

2016-01-26 5:48 am
扣診,無異常發現
心臟:
週期性心跳,沒有聽見可聞雜音或奔馬律
腹部:檢查腫脹的結果,沒有看見腹部包塊,也沒有明顯的排便運動
聽診的結果是活躍的腸鳴音
觸診可捫及下腹部的腫塊
扣診,沒有局灶性鼓音或濁音
無肋脊角扣壓痛
直腸和生殖器:未發現異常
四肢:自由移動四肢
無足浮腫
神經系統檢查:
顱神經:完整
肌肉力量:對稱超過4肢5+
感覺:無感覺異常
步態:間歇性跛行(-)
括約肌功能:完好
初步實驗數據和圖像:

評論初始實驗室數據和圖像:

初步診斷
1.左腹股溝疝


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