04-29胆囊结石英语查房项娅妮.docVIP

Liu nurse: Welcome warmly the nursing department leadership nurses, nursing sisters to guide the work of our department. The contents is patients care of Gallbladder stones with diabetes. As limited, please give us help, thank you! here is the responsibility of nurse Xiang Yani to describe the condition: 刘护士长：热烈欢迎护理部领导、各位护士长、护士姐妹们来我科指导工作，我们查房的内容是胆囊结石合并糖尿病的护理，由于水平有限，准备时间不充分，不足之处，请给以帮助指导。下面请护士项娅妮介绍病情: Xiang Yani: Good afternoon,Teachers, I am a level one nurse Xiang Yani,I was the day of the duty nurse, here I introduce the patients condition. 项娅妮：各位老师，大家下午好，我是NI级护士项娅妮，同时也是患者的责任护士，下面我为大家介绍病人情况。 Nursing round The Nursing of the Gallbladder stones with diabetes 护理查房 胆 囊 结 石 合 并 糖 尿 病 的 护 理 Introduction: Patients with Sun Zhimings disease, male, 57 years old, the number of hospitalized patients: 601498 in March 30, 2015 11:20 entered the ward, with epigastric fullness discomfort over January. Patient with gallbladder stone and cholecystitis income my division. Go to already healthy patients. There are a total of more than 30 years history of smoking and drinking, no drug allergy and other allergic history. More than 40 years ago measles caused by hypertension is blind in the left eye, more than three years, regularly taking metoprolol, ale, Feiluodiping Huanshi Pian, aspirin, aspirin has been disabled for eight days. More than one year for diabetes, insulin, acarbose, pre hospital outpatient B ultrasound tip of gallbladder stones. 病情简介：患者孙志明，男，57岁，住院号：601498。患者于2015年3月30 日11:20步入病房，主诉“上腹饱胀不适一月余”。门诊以胆囊结石并胆囊炎收入我科,患者有吸烟饮酒史30余年，已戒烟酒一年。无药物过敏及其他过敏史。40余年前因“麻疹”致左眼失明，右眼视力正常。高血压病史三年余，能遵医嘱按时服用倍他乐克、阿乐、非洛地平缓释片、阿司匹林等药物，阿司匹林已停用八天。糖尿病一年余，曾在内分泌科治疗，能自行注射甘精胰岛素，口服阿卡波糖，入院前门诊B超提示胆囊结石。 T36.2℃, P72 times / min, BP110/70mmHg. The spirit of good, normal appetite, physical strength is normal, normal sleep, urine normal, no significant changes in body weight, abdominal palpation: abdomen soft, no muscle tension, without apparent tenderness and rebound tenderness, did not touch bag piece, t