药物中毒主诉书范文

药物中毒主诉书范文
英文回答：
Chief Complaint: Drug Poisoning.
History of Present Illness: The patient, a 35-year-old male, presents with symptoms of drug poisoning. He reports ingesting an unknown quantity of medication approximately 2 hours ago. The patient complains of dizziness, nausea, vomiting, and abdominal pain. He denies any history of drug abuse or overdose.
Past Medical History: The patient has a history of hypertension and is currently taking medication for this condition. He denies any known drug allergies.
Social History: The patient reports occasional alcohol use but denies any illicit drug use. He is employed as a construction worker and lives with his wife and two children.
Review of Systems: The patient denies any recent illnesses, fevers, chills, or changes in bowel or bladder habits. He reports no recent travel or exposure to sick individuals.
Physical Examination: On examination, the patient is alert and oriented. Vital signs are within normal limits. He appears uncomfortable and is diaphoretic. His abdomen is tender to palpation in the epigastric region.
Laboratory Tests: Blood tests reveal elevated liver enzymes and metabolic acidosis. Urine toxicology screen is positive for the presence of benzodiazepines.
Diagnosis: Acute drug poisoning, likely due to benzodiazepine overdose.
Treatment Plan: The patient will be admitted to the hospital for further monitoring and management of his symptoms. He will receive supportive care, including intravenous fluids and close monitoring of his vital signs.
The toxicology team will be consulted for further management of the overdose.
Disposition: The patient will be admitted to the
medical-surgical unit for further observation and treatment.
中文回答：
主诉，药物中毒。

现病史，患者，一名35岁男性，出现药物中毒症状。

他报告大
约2小时前摄入了未知数量的药物。

患者抱怨头晕、恶心、呕吐和
腹痛。

他否认有药物滥用或过量服用的历史。

既往史，患者有高血压病史，目前正在服用药物治疗。

他否认
有已知的药物过敏史。

社会史，患者报告偶尔饮酒，但否认使用任何非法药物。

他是
一名建筑工人，与妻子和两个孩子同住。

系统回顾，患者否认最近有疾病、发热、寒战或排便、排尿习
惯的变化。

他报告没有最近的旅行或接触到有病的人。

体格检查，检查时，患者神志清楚。

生命体征正常。

他看起来不舒服，出现了大汗。

他的上腹部压痛。

实验室检查，血液检查显示肝酶升高和代谢性酸中毒。

尿毒理学筛查呈苯二氮卓类阳性。

诊断，急性药物中毒，很可能是苯二氮卓类药物过量。

治疗计划，患者将被送往医院进一步监测和管理症状。

他将接受支持性治疗，包括静脉输液和密切监测生命体征。

毒理学团队将被咨询以进一步处理过量服用的问题。

处置，患者将被送往内科外科病房进行进一步观察和治疗。