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急急急~~幫我翻譯一下醫學內容~~20點
May 16th 2013, 05:22
Chief complaint:
For 4th course of chemotherapy with HDFL and CDDP
Present illness
This 53y/o patient was acase of*.Breast cancer , left post modified radical mastectomy(1998.4),pT2NOMO,stageII ER(+),PR(-)Her-2(++)with bone metastasis s/p biphosphonate,ascending-colon,right orbital region and liver etastasis,chemotherapy with regimen of 9 courses of CMF(1998.5-1998.10),Vinorelbine/HDFL(2003.4),4 courses of AC(2003.8.4,2003.8.26,2003.9.16,2002.10.8) and palliative radiotherapy(2003.4)with recurrence ER:+ S/P. Femarra,Aromasin,Phyxol+Gemzar,Endoxan+Xeloda,,Farlutal and tri-weekly LipoDox.She was recieved regular follow up at our HEM OPD.Abdominal MRI for regular follow up revealed Multiple(number: at least=7)newly developed nodules on right hepatic lobe are noted. As compared with prior MRI study on 20120827, these hepatic nodules show INCREASE in size and number. She underwent chemotherapy with oral Etoposide(Vepesid) and Tamoxifen (nolvadex) at HEM OPD from Sep 2012 to Feb 2012.Abdomoninal MRI on 20130129 showed multiple metastases on both hepatic lobes show INCREASE in size and number. Therefore, She was admitted for scheduled chemotherapy.
Past history:
*.Denied the Hx of hypertension, DM, or other systemic diseases.
*.Denied the HX of other operation
Personal history:
*.No habit of cigarette smoking or alcohol drinking
Family history:
Family history is nothing in particular
Allergy history:
NKA
Drug resistance
None
Psychosocial Assessment:
Review of systems:
Positive finding : mild fatigue , mild pain over the right supra orbitol region.
Negative finding : no nausea , no weight loss , no chills , no night sweating , no hemoptysis , no epistaxis , no chest tightness , no chest pail , no abdominal pain , no anorexia , no constipation , no diarrhea , no hematemesis , no hematochezia , no melena , no dysuria , no oligouria , no midnight pain , no post-prandial pain , no hungry pain .
Physical examinations:
- 2013-05-16 13:23:04 補充
Vital signs: BT:36.5℃ BP:122/84mmHg PR:73/min RR:18/min
General appearance:A moderate-developed and moderate-nourshed male.lying on bed with generally fine looking appearance,without cardiopulmonary embarrassment.
Conscious : aleart Mentality : intact to JOMAC
Skin : Petechiae or ecchymosis(一),rash(
- 2013-05-16 13:24:34 補充
bedsore(一),normal skin turgur
HEENT:Conj:pale(一),sclera:icteric(一),pupils:iscoricL/R +/+ 2.0/2.0mm
Pigmentation on frontal region
Neck : supple,jugular veim engorgement(一),2cm above Louiss angle at 45*,carotid brouits(一),LAP(一),Goiter(一)
Chest : symmetrical&free expansion,clear breath sound,wheezing
- 2013-05-16 13:24:50 補充
rales(一)
Heart : regular heart beat , PMI at 5th ICS icm lateral LMCL , no murmur , no heave , no thrill , no s3/s4
Abdomen : soft and falt , normoactive bowel sound , built(一) , L/S: impalpable , shifting dullress(一),Murphy•s sign(一) , tenderness(一) , rebounding pain(一) , succusion splasn(一)
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