英文病例汇报模板.ppt

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1、CASEREPORTDepartmentofGeneralSurgerMay12th,2016MedicalRecordsforAdmissionName：Sex:femaleAge:31RegistrationNo.:Dateofadmission：ChiefcompliantTwomonthsafterappendicectomy；RecurrentabdominalpainassociatedwithfeverforonemonthPresenthistory1rightventralabdominalpain，2monthsagoappendicectomyinHongkon

2、gabdominalpainassociatedwithfeverforonemonthmaximumbodytemperatureupto38.9℃TherearenosimilardiseasesinhisfamilyFamilyHistoryrightlowabdominalpainstenderness（+）、Reboundtenderness（+）;PhysicalExaminationBloodroutineurineroutine4/21coagulationfunctionLiverfunctiontest4/21Tumormarker4/7LABFINDINGSIm

3、ageologicalexamination: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。CTDescription：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。CT1、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。Diagnosis1.appendicitisa

4、fterappendectomy2.AbdominalAbscessDiscusion：furthertreatment?