英文病例汇报模板

40--75%
4.82 4.8
4.74 4.49 4.36 X10~12/L 3.8--5.1
HB
110
114
112
106
103
g/L
115-150g/L 125-350X10~9/ L
PLT
398
373
389
413
370
X10~9/L
urine routine
LEU UWBC 3+ 44.3 Baidu Nhomakorabeaul -
Imageological examination: 1、肝胆胰脾、双肾输尿管、膀胱、子宫 、附件无殊。 2、右下腹非均质性包块。
CT
Description：
右侧回盲部见斑片状软组织密度影及条索影 ，边缘毛糙，约29x43mm，增强明显不均匀强 化，内低密度坏死去无强化，右侧腹壁下见略 不规则环形强化影。阑尾区少量积气，见高密 度结石夹留置，呈术后改变，周围见多个稍大 淋巴结，增强明显强化。
Rebound tenderness（+）;
Blood routine
21-Apr 29-Apr 4-May 8-May 10-May WBC
14.37 12.3 10.34 14.619.42 X10~9 /L 3.5--9.5
NEUT% 82.4 RBC
83.3 85.5 88.7 84.1 %
Discusion：
further treatment?
4/21
0--23/ul
URBC EC
BXBGBSY HXBGBSY
8.4 4.8
8 1.5
/ul /ul
/HPF /HPF
0--18/ul 0--3/ul
0--5个/HP 0--3个/HPF
coagulation function
PT
INR APTT TT
15.3
1.33 37.9 18.2
s
10--14s
Tumor marker
AFP
CEA CA125
4/7
11.2
0.48 22.1
ng/ml
ng/ml U/mL
0.89--8.78ng/ml
0--10ng/ml 0--35U/mL
CA153
CA199
5.5
7.5
U/mL
U/mL
0--28U/mL
0--37U/mL
LAB FINDINGS
ESR 24 mm/h 0--20mm/h
maximum body temperature up to 38.9℃
Family History
There are no similar diseases in his family
Physical Examination
right low abdominal pains tenderness（+）、
Two months after appendicectomy；
Recurrent abdominal pain associated
with fever for one month
Present history 1
right ventral abdominal pain，2 months ago appendicectomy in Hongkong abdominal pain associated with fever for one month
s s
23--35s 14--21s
FBG
3.72
g/L
1.7--4.5g/L
Liver function test
TP ALB ALP GGT ALT AST 67.5 34.1 51.8 23.2 6.9 12 g/L g/L U/L U/L U/L U/L
4/21
65--85g/L 40--55g/L 35--100U/L 7--45U/L 7--40U/L 13--35U/L
CT
1、阑尾术后改变并回盲部、阑尾周围脓肿， 建议治疗后复查； 2、阑尾周围多发淋巴结影； 3、肝右叶后上段不典型小血管瘤多考虑，随 访； 4、阴道穹窿部少量积液，请结合临床考虑。
Diagnosis
1. appendicitis after appendectomy
2. Abdominal Abscess
CASE REPORT
May 12th, 2016
Department of General Surger
Medical Records for Admission
Name： Sex: female Age: 31 Registration No.: Date of admission：
Chief compliant