英文病例汇报模板.ppt

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1、CASE REPORTDepartment of General Surger May 12th,2016Medical Records for AdmissionName：Sex:female Age:31 Registration No.:Date of admission：Chief compliantlTwo months after appendicectomy；lRecurrent abdominal pain associated with fever for one month Present history 1l right ventral abdominal pain，2

2、months agolappendicectomy in Hongkonglabdominal pain associated with fever for one monthlmaximum body temperature up to 38.9 There are no similar diseases in his family Family Historyright low abdominal pains tenderness（+）、Rebound tenderness（+）;Physical ExaminationBlood routine urine routine4/21coag

3、ulation functionLiver function test4/21Tumor marker4/7LAB FINDINGSI Imageological examinationmageological examination:1 1、肝胆胰脾、双肾输尿管、膀胱、子宫、肝胆胰脾、双肾输尿管、膀胱、子宫、附件无殊。附件无殊。2 2、右下腹非均质性包块。、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，右侧回盲部见斑片状软组织密度影及条索影，边缘毛糙，约边缘毛糙，约29x43mm，增强明显不均匀强化，增强明显不均匀强化，内低密度坏死去无强化，右侧腹壁

4、下见略不规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。结，增强明显强化。CT1、阑尾术后改变并回盲部、阑尾周围脓肿，、阑尾术后改变并回盲部、阑尾周围脓肿，建议治疗后复查；建议治疗后复查；2、阑尾周围多发淋巴结影；、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、肝右叶后上段不典型小血管瘤多考虑，随访；访；4、阴道穹窿部少量积液，请结合临床考虑。、阴道穹窿部少量积液，请结合临床考虑。Diagnosis1.1.appendicitis after appendectomy appendicitis after appendectomy2.Abdominal Abscess2.Abdominal AbscessDiscusion：further treatment?