第1个回答 2011-11-23
Admission date: June 12, 2010 discharge date: June 23, 2010 11 days of hospitalization
Admission diagnosis: right ear for sudden deafness
Discharge diagnosis: right ear for sudden deafness
At the time of admission:" right ear tinnitus and hearing loss of 1 months" as the chief complaint of admission. Check the body: T: 36.6 C P: 80 times / min R: BP : 140 / 90mmHg / min.. Double ear without deformity, ear canal cleaning, ear membrane integrity, no congestion, the mastoid area without tenderness, W - > left. Determination of pure-tone audiometry domain shows: the right ear sensorineural deafness.
After treatment : the patients after admission to perfect the relevant examination, routine blood test, urine routine, biochemical series, hepatitis, syphilis, AIDS antibody reaction series, electrocardiogram, chest radiographs showed no abnormality. Determination of pure-tone audiometry domain shows: the right ear sensorineural deafness. Clindamycin injection to 0.9g joined 250ml saline once a day and 7 days, 3 days of dexamethasone 5mg static point, energy mixture on a static point 11 days. In the 2010613 and 2010622 rows of the right ear after closure, local ear ultrashort wave therapy, review of pure tone audiometry: ear showed significantly better verbal average hearing threshold, improved 10dB, improved discharge today.
At discharge: general condition, the spirit of good, right ear hearing relatively before increase, tinnitus relief. Physical examination: the ear canal cleaning, ear membrane integrity, no congestion, the mastoid area without tenderness. W - > left ear.
Discharge instructions: 1 oral yellow Dougan element sheet
2.2 weeks after the visit
望采纳!!
第2个回答 2011-11-20
Admission date: June 12, 2010 discharge date: June 23, 2010 hospitalized 11 days
Admission diagnosis: sudden deafness right ear
Discharge diagnosis: sudden deafness right ear
Admission cases: the "right ear tinnitus with hearing loss a month," hospital chief complaint. Physical examination: T: 36.6 ℃ P: 80 beats / min R: beats / min BP: 140/90mmhg. No double-ear deformity, canal cleaning, ears tympanic membrane integrity, no congestion, the mastoid area without tenderness, w-> left. Determination of pure tone domain show: the right ear sensorineural hearing loss.
After treatment: the risk of admission to hospital improve the relevant examination, routine blood, urine, biochemical series, hepatitis series, syphilis reaction, HIV antibody, electrocardiogram, chest ray films showed no abnormalities. Determination of pure tone domain show: the right ear sensorineural hearing loss. To Clindamycin Injection 0.9g 250ml normal saline on a static point of 7 days, intravenous dexamethasone 5mg three days on a static point energy mixture for 11 days. At 2,010,613 and 2,010,622 lines closed after the right ear, the ear of local FM therapy, review the determination of pure-tone audiometry showed: right ear marked improvement over the previous hearing, speech, hearing threshold increased an average of 10db, improved and discharged today.
Discharge conditions: general conditions may be, the spirit is good, right ear increase over the previous hearing, tinnitus relief. Examination: canal cleaning, ears tympanic membrane integrity, no congestion, no tenderness in the mastoid area. W-> left ear.
Discharge Instructions: 1. Oral daidzein tablets
2.2 weeks after the referral.