apical region wall motion abnormali

apical region wall motion abnormality, Suspect ACS and unstable angina, so we check cardiac enzyme Q6H and PRN, fllow up EKG PRN, O2 support and Premix-NTG keep run 0.5-10ml/hr. CXR revealed Bilateral lung infiltration, RLL pnumonia patch then check Sputum Culture(mix), Gram's stain (mix), H.influenza B Ag(Negative), S.pneumoniae Ag(Negative), Mycoplasma pneumoniae Ab(1:40x(-)) and Legionella urinary Ag(Negative). Abdomen distension, abdomen op wound mild redder, J-P drainage smooth, NG drainage showed 墨綠色 large amout was noted but hemoglobin no decrease, KUB showed Ileus, abdominal distension suspected related to anastomosis leakage or anastomosis stenosis or ileus, check Aerobic Culture(Ascites), Anaerobic Culture (Ascites) and Amylase(Ascites)=124 on 11-01. abdomen still distension plus NG drainage large amout, so adjustment Pantoloc 40mg 5vail in NS 50ml run 2ml/hr; Shift Oliclinomel emulsion 1500ml run 63ml/hr, add Lasix 40mg 1amp ivd q8h and Dulcolax supp 10mg 2# EN HS for prevention constipation and promote gastrointestinal motility on 11-02. His clinical condition became mild stablized after treatment, so he was transferred to surgical ward for further care on 2019-11-04.

結果 (英文) 1:

apical region wall motion abnormality, Suspect ACS and
unstable angina, so we check cardiac enzyme Q6H and PRN, fllow up EKG PRN, O2
support and Premix-NTG keep run 0.5-10ml/hr. CXR revealed Bilateral lung
infiltration, RLL pnumonia patch then check Sputum Culture(mix), Gram's stain
(mix), H.influenza B Ag(Negative), S.pneumoniae Ag(Negative), Mycoplasma
pneumoniae Ab(1:40x(-)) and Legionella urinary Ag(Negative). Abdomen distension,
abdomen op wound mild redder, J-P drainage smooth, NG drainage showed 墨綠色
large amout was noted but hemoglobin no decrease, KUB showed Ileus, abdominal
distension suspected related to anastomosis leakage or anastomosis stenosis or
ileus, check Aerobic Culture(Ascites), Anaerobic Culture (Ascites) and
Amylase(Ascites)=124 on 11-01. abdomen still distension plus NG drainage large
amout, so adjustment Pantoloc 40mg 5vail in NS 50ml run 2ml/hr; Shift
Oliclinomel emulsion 1500ml run 63ml/hr, add Lasix 40mg 1amp ivd q8h and
Dulcolax supp 10mg 2# EN HS for prevention constipation and promote
gastrointestinal motility on 11-02. His clinical condition became mild
stablized after treatment, so he was transferred to surgical ward for further
care on 2019-11-04.

結果 (英文) 3:

心尖部室壁运动异常，疑似ACS和
不稳定型心绞痛，所以我们检查心肌酶Q6H和PRN，fllow up EKG PRN，O2
支持和预混料NTG保持0.5-10毫升/小时CXR显示双侧肺
浸润，RLL pnumonia贴片检查痰培养（mix），革兰氏染色
（混合型）、乙型流感病毒抗原（阴性）、肺炎链球菌抗原（阴性）、支原体
肺炎Ab（1:40x-）和军团菌尿Ag（阴性）腹胀，
腹部手术伤口轻度发红，J-P引流通畅，NG引流显示
出现大量出血，但血红蛋白没有下降，KUB显示肠梗阻，腹部
怀疑与吻合口漏或吻合口狭窄有关的扩张或
肠梗阻，检查需氧培养（腹水）、厌氧培养（腹水）和
淀粉酶（腹水）=11-01上的124腹胀加鼻胃管引流大
数量，因此调整Pantoloc 40毫克5毫升，NS 50毫升，每小时2毫升；班次
立克宁乳状液1500ml，滴入63ml/hr，加入Lasix 40mg 1amp ivd q8h
杜拉克拉司（Dulcolax supp）10mg 2#EN-HS预防便秘和促进
胃肠动力11-02他的临床症状变得温和了
治疗后情况稳定，所以他被转到外科病房继续治疗
关注2019-11-04。