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英文病例汇报模板


Discusion:
further treatment?
携手共进,齐创精品工程
Thank You
世界触手可及
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
、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。
Blood routine
urine routiion
Liver function test 4/21
Tumor marker
4/7
LAB FINDINGS
Imageological examination: 1、肝胆胰脾、双肾输尿管、膀胱、子宫
英文病例汇报模板
Medical Records for Admission
Name: Sex: female Age: 31 Registration No.: Date of admission:
Chief compliant
Two months after appendicectomy; Recurrent abdominal pain associated
month
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(+);
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
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