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Services
MT post-editing, Translation
Compétences
Spécialisé en :
Finance (général)
Droit : contrat(s)
Économie
Génétique
Investissement / titres
Médecine : soins de santé
Droit (général)
Droit : brevets, marques de commerce, copyright
Médecine (général)
Médecine : médicaments
Autres domaines traités :
Bétail / élevage
Entreprise / commerce
Certificats / diplômes / licences / CV
Gouvernement / politique
Médecine : cardiologie
Medical: Oncology
Énergie / génération d'électricité
Org / dév. / coop internationale
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Bénévolat / Travail pro bono
Est disponible pour travailler bénévolement pour des organisations à but non lucratif enregistrées
espagnol vers anglais: A&E REPORT General field: Médecine Detailed field: Médecine : soins de santé
Texte source - espagnol Informe d´urgències
Constants a l'ingrés (21:59h):
Temp: 36.2 FC: 79 TAS: 138 TAD: 77 Sat.02: 98 Dolor: 3 Glicèmia: 126
Al-lèrgies:
No té al-lèrgies
Antecedents :
Procedente de Londres
HTA
Dislipidemia
Medicació actual :
amlodipino 10mg/dia
Atorvastatina 20mg/dia
Malaltia actual:
paciente quien presenta episodio súbito de náuseas, diaforesis, desconexión del medio y posterior relajación de esfínteres con rigidez generalizada de pocos segundos de duración, no traumatismo craneal. Recuperación espontánea. Asistido por paramédicos en el restaurante con constantes normales, sin focalidad neurológica
Exploració :
Alerta, orientado en las tres esferas, afebril, anictérico
c/p RSCs rítmicos no sobregregados pulmonares
ext no edemas
neuro FM 5 /5 no desviación de comisura labial, no afasia ni alteraciones en el lenguaje, anisocoria midriasis derecha con movimientos oculares normales, niega alteraciones visuales
Analítica :
Orina:
Uri_Densitat rel. 1010 g/mL, Uri_Orina; pH 7.5 , Uri_Proteína; c.arb. Negatiu mg/dL, Uri_Glucosa; c.arb. 250.00 mg/dL, Uri_Acetoacetat; c.arb. Negatiu , Uri_Bilirubina; c.arb. Negatiu , Uri_Hemoglobina(Fe); c.arb. Negatiu , Uri_Nitrit; c.arb. Negatiu , Uri_Urobilinogen; c.arb. Normal mg/dL, Uri_Esterasa leucocítica; c.arb. Negatiu cel/μL
Hemograma:
Leucócits;c.nom. 11.66 xl0A3_u/mcL, Eritrócits;c.nom. 4.56 xlOA6_u/mcL, Hemoglobina; c.massa 15 g/dL, Eritrócits;fr.vol. (Hematocrit) 42 %, Plaquetes;c.nom. 131.0 xlOA3_u/mcL, Neutrófils;fr.nom. 84.60 %, Limfócits;fr.nom. 10.30 %,
Coagulació:
Temps protrombina: Activitat % (T.protrombina) 100.0 %, INR 0.97 [INR], Temps pacient (TTPA) 26.00 s, Raó (TTPA) 0.8 [raó], Glucosa 200.0 mg/dL, Srm_Creatinini; c.subst. 0.9 mg/dL, Filtrat Glomerular CKD-EPI 89.21 , Urea 12.6 mg/dL, ló sodi 139.0 mmol/L, ló potassi 3.2 mmol/L, Calci 8.3 mg/dL, Bilirubina 1.13 mg/dL, ALT IFCC 26.4 U/L, Alfa-amilasa 64.80 U/L, CK IFCC 428.4 U/L, Troponina I alta sensibilitat Atellica 4.00 ng/L, PCR 1.66 mg/L,
Gasometría venosa:
v pH 7.431 , v PCO2 37.5 mmHg, v PO2 50.7 mmHg, v HCO3A 24.5 mmol/L, v ABE 1.00 , v O2SAT 82.6 %, Lactat URG 1.6 mmol/L
Servei de diagnostic per la imatge :
TAC cráneo
TÉCNICA: Se realiza TC de cráneo desde vértex hasta foramen magno, sin administración de contraste endovenoso. No se disponen de estudios previos para hacer un estudio comparativo. HALLAZGOS: No se observan lesiones hemorrágicas intra/extraparenquimatosas agudas. Sistema ventricular de tamaño normal. Parénquima cerebral, cerebeloso y de tronco-encéfalo sin alteraciones densiométricas o morfológicas valorables. Estructuras de línea media supra e infratentoriales no desplazadas. Cisternas básales y peritronculares libres. Marco óseo sin hallazgos significativos.
Conclusions:
Estudio TC cráneo urgente en que no se evidencian alteraciones intracraneales agudas.
ECG :
Ritmo sinusal a 96/min QRS estrecho no supra ni infradesniveles Evolució :
Analítica sanguínea mínima leucocitosis y neutrofilia, trombocitopenia leve. Hipopotasemia se inicia reposición CK elevadas. Leve hiperglicemia con glucosuria. Acetonas negativas. Pendiente TAC cráneo. Vigilancia neurológica
TAC cráneo normal. Solicito 1C neurología.
9:30 a.m. Dra. Silvia Regina Pedrozo.
Asumo paciente de la guardia anterior, valorado por Dra. García, con los antecedentes descritos arriba. Analítica sanguínea control: K 3.3 (hipopotasemia leve).
En espera de valoración por Neurología.
Neurología Dra. Vanesa Adell.
Realizo 1C de paciente 57 años, HTA, DLP, HIV bien controlado. Acude a urgencias porque ayer a la hora de la cena tuvo episodio de pérdida de conciencia precedida de pródromos en forma de sudoración, malestar general y náuseas. Pérdida de conciencia con rigidez generalizada y movimientos de corta duración con rápida recuperación del nivel de conciencia. Tras recuperarse tuvo necesidad de defecar. A su llegada al SEM normocosntante sin focalidad NRL. Se realiza analítica que muestra leve leucocitosis, plaquetas 125000, glucosa 143, K 3.3, CK 5.79 (N < 2.93). TC craneal normal. ECK FC 96, PR < 0.20, QRS estrecho sin alteraciones de la repolarización. ExpINRL a mi valoración normal sin asimetrías con PICNR. Paciente con buen estado general. OD: sincope convulsivo vasovagal. PLAN: alta por parte de NRL. Valorar si precisa corrección K. Aconsejo control por su médico habitual.
Tractaments administráts a urgéncies :
captopril 25mg
SSN 0.9% 500cc + cloruro de potasio 20mEq
Diagnostics:
780.2-SINCOPE Procediments :
89.7-EXAMEN FISIC GENERAL Recomanacions i tractament a l'alta :
Continuar con medicación habitual.
Ingesta de alimentos ricos en potasio (zumos de frutas).
Control y seguimiento por su médico de cabecera de cabecera.
Acudir a urgencias en caso de presentar nuevos síntomas, signos de alarma.
Interconsultes:
Neurologia (Vanesa Adell Ortega 04.07.2023 a les 10:12h) : Realizo 1C de paciente 57 años, HTA, DLP, HIV bien controlado. Acude a urgencias porque ayer a la hora de la cena tuvo episodio de pérdida de conciencia precedida de pródromos en forma de sudoración, malestar general y náuseas. Pérdida de conciencia con rigidez generalizada y movimientos de corta duración con rápida recuperación del nivel de conciencia. Tras recuperarse tuvo necesidad de defecar. A su llegada al SEM normoconstante sin focalidad NRL. Se realiza analítica que muestra leve leucocitosis, plaquetas 125000, glucosa 143, K 3.3, CK 5.79 (N < 2.93). TC craneal normal. ECK FC 96, PR < 0.20, QRS estrecho sin alteraciones de la repolarización. ExpINRL a mi valoración normal sin asimetrías con PICNR. Paciente con buen estado general. OD: sincope convulsivo vasovagal. PLAN: alta por parte de NRL. Valorar si precisa corrección K. Aconsejo control por su médico habitual.
Traduction - anglais A&E REPORT
Constants at admission (9:36 p.m.):
Temp: 36.2 HR: 79 SBP: 138 DBP: 77 SatO2: 98 Pain: 3 Glycemia: 126
Allergies:
He has no allergies
History:
From London
HBP
Dyslipidaemia
Current medication:
Amlodipine 10 mg/day
Atorvastatin 20 mg/day
Current illness:
patient who presented with a sudden episode of nausea, diaphoresis, disconnection from the environment and subsequent sphincter relaxation with generalised rigidity lasting for a few seconds, no cranial trauma. Spontaneous recovery. Cared for by paramedics in the restaurant with normal vital signs, no neurological focality.
Examination:
Alert, oriented to person, place and time, anicteric
with rhythmic heart sounds, no adventitious breath sounds
ext no oedema
neuro FM 5 /5 no deviation of labial commissure, no aphasia or language disturbances, anisocoria right mydriasis with normal eye movements, he denied any visual disturbances
Tests:
Urine:
Uri_Rel. Density 1010 g/ml, Uri_Urine; pH 7.5, Uri_Proteins; arbitrary concentration Negative mg/dl, Uri_Glucose; arbitrary concentration 250.00 mg/dl, Uri_Acetoacetate; arbitrary concentration Negative, Uri_Bilirubin; arbitrary concentration Negative, Uri_ Haemoglobin (Fe); arbitrary concentration Negative, Uri_Nitrite; arbitrary concentration Negative , Uri_Urobilinogen; arbitrary concentration Normal mg/dl, Uri_ Leukocyte Esterase; arbitrary concentration Negative cel/μl
Complete blood count:
Leukocytes; number concentration [the figure followed by the unit of measurement right next to it in this case, a Catalan standardised form of overstating the obvious used in the source before measurements with a list of similar acronyms not found or used elsewhere which can be felt to be redundant] 11.66 x10A3_μ/mcl, Erythrocytes; number concentration 4.56 x10A6_μ/mcl, Haemoglobin; mass concentration 15 g/dl, Erythrocytes; volume formula (Haematocrit) 42%, Platelets; number concentration 131.0 x10A3_μ/mcl, Neutrophils; number formula 84.60%, Lymphocytes; number formula 10.30%,
Coagulation:
Prothrombin time: Activity % (Prothrombin T.) 100.0%, INR 0.97 [INR], Patient time (aPTT) 26.00 s, Ratio (aPTT) 0.8 [ratio], Glucose 200.0 mg/dl, Srm_Creatinine; substance concentration 0.9 mg/dl, Glomerular Filtration Rate CKD-EPI 89.21, Urea 12.6 mg/dl, sodium ion 139.0 mmol/l, potassium ion 3.2 mmol/l, Calcium 8.3 mg/dl, Bilirubin 1.13 mg/dl, ALT IFCC 26.4 U/l , Alpha-amylase 64.80 U/l, CK IFCC 428.4 U/l, Troponin I high sensitivity Atellica 4.00 ng/l, CRP 1.66 mg/l,
Venous blood gases:
v pH 7.431 , v PCO2 37.5 mmHg, v PO2 50.7 mmHg, v HCO3A 24.5 mmol/l, v ABE 1.00 , v O2SAT 82.6%, A&E Lactate 1.6 mmol/l
Diagnostic imaging department:
Skull CT scan
TECHNIQUE: A skull CT scan was performed from the vertex to the foramen magnum, without administering any intravenous contrast. No previous studies are available to make a comparative study.
FINDINGS: No acute intra/extraparenchymal haemorrhagic lesions were observed. Ventricular system of normal size. Cerebral, cerebellar and brainstem parenchyma with no assessable densiometric or morphological abnormalities. Supra- and infratentorial midline structures not displaced. Basal and peritroncular cisterns free. Bony framework with no significant findings.
Conclusions:
Urgent skull CT scan in which there was no evidence of acute intracranial abnormalities.
ECG:
Sinus rhythm at 96/min narrow QRS, no ST segment elevation or ST segment depression.
Clinical course:
Blood tests minimal leukocytosis and neutrophilia, mild thrombocytopenia. Hypokalaemia, elevated CK replacement was initiated. Mild hyperglycaemia with glycosuria. Negative ketone bodies. Pending skull CT scan. Neurological surveillance
Normal skull CT scan. I requested a neurology IC.
9:30 a.m. Dr Silvia Regina Pedrozo.
I take over the patient from the previous shift, assessed by Dr García, with the history described above. Control blood test: K 3.3 (mild hypokalaemia).
Awaiting assessment by Neurology.
Neurology Dr Vanesa Adell.
I conducted the IC of a 57-year-old patient, hypertension, DLP, well-controlled HIV. He presented to the accident and emergency department because he experienced yesterday at dinner time an episode of loss of consciousness preceded by prodromes in the form of sweating, general malaise and nausea. Loss of consciousness with generalised rigidity and short-lasting movements with rapid recovery of the level of consciousness. After recovery, he felt the need to defecate. On arrival at the A&E he had normal constants without NRL focality. Blood tests showed mild leukocytosis, platelets 125000, glucose 143, K 3.3, CK 5.79 (N < 2.93). Normal skull CT scan. ECK FC 96, PR < 0.20, narrow QRS without repolarisation abnormalities. NRL exam normal according to my assessment with no asymmetries with PEARL (pupils equal and reacting to light). Patient in good general condition. OD: vasovagal convulsive syncope. PLAN: discharge by NRL. To be assessed whether K correction is required. I recommend monitoring by his usual doctor.
Treatments administered in the A&E:
captopril 25 mg
Saline 0.9% 500 cc + potassium chloride 20 mEq
Diagnoses:
780.2-SYNCOPE
Procedures:
89.7-GENERAL PHYSICAL EXAMINATION
Recommendations and treatment upon discharge:
Continue with regular medication.
Intake of foods rich in potassium (fruit juices).
Control and monitoring by your GP.
Go to the emergency department in case of new symptoms, warning signs.
Interconsultations:
Neurology (Vanesa Adell Ortega 04.07.2023 at 10: 40 a.m.): I conducted the IC of a 57-year-old patient, hypertension, DLP, well-controlled HIV. He presented to the accident and emergency department because he experienced yesterday at dinner time an episode of loss of consciousness preceded by prodromes in the form of sweating, general malaise and nausea. Loss of consciousness with generalised rigidity and short-lasting movements with rapid recovery of the level of consciousness. After recovery, he felt the need to defecate. On arrival at the A&E he had normal constants without NRL focality. Blood tests showed mild leukocytosis, platelets 125000, glucose 143, K 3.3, CK 5.79 (N < 2.93). Normal skull CT scan. ECK FC 96, PR < 0.20, narrow QRS without repolarisation abnormalities. NRL exam normal according to my assessment with no asymmetries with PEARL (pupils equal and reacting to light). Patient in good general condition. OD: vasovagal convulsive syncope. PLAN: discharge by NRL. To be assessed whether K correction is required. I recommend monitoring by his usual doctor.
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Études de traduction
Master's degree - London Metropolitan University
Expérience
Années d'expérience en traduction : 14. Inscrit à ProZ.com : Oct 2009.
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Bio
Language has been a life-long passion growing immersed in more than one culture. I am a British citizen brought up bilingual in a multilingual setting. This lifelong passion has taken me to live and attend university in the United States, Spain and eventually to come back to the UK and settle here for the last 23 years. I have worked as a translator for more than 10 years on my own mainly in the legal and medical sciences field trading as Nuance Translations Limited. I also worked for two years as a linguist in an intellectual property firm in the City of London, shortly after completing my MA in Specialised Translation with a distinction.
Mots clés : Portuguese, Spanish, French, Galician, medical, life sciences, legal, financial, CRO, intellectual property. See more.Portuguese, Spanish, French, Galician, medical, life sciences, legal, financial, CRO, intellectual property, CAT tools. See less.
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