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发布者:鑫达医学翻译 发布时间:2013-05-21 8:50:52 阅读:

原文:
患者入院后未再出现胸痛等不适。双肺呼吸音清,未及明显干湿罗音,HR 65-80bpm,心律齐,未及心脏杂音,腹部软,无压痛。
林大夫查房:患者目前继续给予冠心病二级预防,克赛可再用三天。
患者今日一般情况好,无不适主诉。
查体:双肺清,未及啰音,HR 70bpm,心律齐,杂音(-)。双侧乳房未及明显包块。
林大夫查房:患者目前继续给予冠心病二级预防,今日起停用克赛,建议患者适量活动。
患者今日病情相对平稳,无明显不适主诉,患者已经下地活动,患者安静时心率多在60-70bpm,但稍活动心率可增加为80-90 bpm。
查体:双肺呼吸音清,未及干湿罗音啰音,HR 70,心律齐,未及心脏杂音,腹部软,无压痛。

译文:
No chest pain was reported after admission. No abnormalities were detected in the vesicular breath sound. No Rhonchi or moist rales were noted. The heart rate ranged from 65 to 80bpm. The heart rhythm is normal. No cardiac murmur was reported.
Description of ward-round by Dr Lin: Secondary prevention of coronary heart disease should be continued. Clexane could be taken for another 3 days.
The patient showed stable health conditions. No discomfort was reported.
For the physical check, no abnormalities were detected in the vesicular breath sound. No Rhonchi or moist rales were noted. The heart rate is 70bpm. No significant tumor mass was noted in the bilateral lacteal gland.
Description of ward-round by Dr Lin: Secondary prevention of coronary heart disease should be continued. The Clexane can be quitted. Appropriate exercises are recommended.
The patient showed stable health conditions. No discomfort was reported.
No abnormalities were detected in the vesicular breath sound. No Rhonchi or moist rales were noted. The heart rate is 70 bpm. The heart rhythm is normal. No cardiac murmur was reported. No pressing pain was reported in the abdomen.
 


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