英文病例汇报模板.ppt

CASEREPORT DepartmentofGeneralSurger May12th 2016 MedicalRecordsforAdmission Name Sex femaleAge 31RegistrationNo Dateofadmission Chiefcompliant Twomonthsafterappendicectomy Recurrentabdominalpainassociatedwithfeverforonemonth Presenthistory1 rightventralabdominalpain 2monthsagoappendicectomyinHongkongabdominalpainassociatedwithfeverforonemonthmaximumbodytemperatureupto38 9 Therearenosimilardiseasesinhisfamily FamilyHistory rightlowabdominalpainstenderness Reboundtenderness PhysicalExamination Bloodroutine urineroutine 4 21 coagulationfunction Liverfunctiontest 4 21 Tumormarker 4 7 LABFINDINGS Imageologicalexamination 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 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 appendicitisafterappendectomy2 AbdominalAbscess Discusion furthertreatment