英文病例汇报模板

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。
1C、T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
Discusion：
further treatment?
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
/ul /ul /ul /HPF
/HPF
4/21
0--23/ul 0--18/ul 0--3/ul 0--5个/HP 0--3个/HPF
coagulation function
PT
15.3
s
INR
1.33
APTT
37.9
s
TT
18.2
s
FBG
3.72
g/L
10--14s
23--35s 14--21s 1.7--4.5g/L
Liver function test
TP
67.5
g/L
ALB
34.1
g/L
ALP
源自文库51.8
U/L
GGT
23.2
U/L
ALT
6.9
U/L
AST
12
U/L
4/21
65--85g/L
40--55g/L 35--100U/L
7--45U/L 7--40U/L
13--35U/L
Tumor marker
AFP 11.2 CEA 0.48 CA125 22.1 CA153 5.5 CA199 7.5
ng/ml ng/ml U/mL U/mL U/mL
4/7
0.89--8.78ng/ml 0--10ng/ml 0--35U/mL 0--28U/mL 0--37U/mL
LAB FINDINGS
ESR 24
mm/h 0--20mm/h
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。
maximum body temperature up to 38.9℃
Family History
There are no similar diseases in his family
Physical Examination
right low abdominal pains tenderness（+）、 Rebound tenderness（+）;
PLT 398 373
4.74 4.49 4.36 X10~12/L 3.8--5.1
112 106 103 g/L
115-150g/L
125--
350X10~9/
389 413 370 X10~9/L L
urine routine
LEU UWBC URBC EC BXBGBSY HXBGBSY
3+ 44.3 8.4 4.8 8 1.5
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
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 83.3 85.5 88.7 84.1 %
40--75%
RBC 4.82 4.8 HB 110 114