英文病例汇报模板.pptx

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1、Medical Records for AdmissionName：Sex:female Age:31 Registration No.:Date of admission：第1页/共17页Chief compliantlTwo months after appendicectomy；lRecurrent abdominal pain associated with fever for one month第2页/共17页 Present history 1l right ventral abdominal pain，2 months agolappendicectomy in Hongkong

2、labdominal pain associated with fever for one monthlmaximum body temperature up to 38.9 第3页/共17页There are no similar diseases in his family Family History第4页/共17页right low abdominal pains tenderness（+）、Rebound tenderness（+）;Physical Examination第5页/共17页Blood routine 21-Apr21-Apr 29-Apr29-Apr4-May4-Ma

3、y8-May8-May 10-May10-MayWBCWBC14.3714.37 12.312.3 10.3410.34 14.6114.619.429.42X109/LX109/L3.5-9.53.5-9.5NEUT%NEUT%82.482.483.383.3 85.585.588.788.7 84.184.1%40-75%40-75%RBCRBC4.824.824.84.84.744.744.494.49 4.364.36X1012/LX1012/L3.8-5.13.8-5.1HBHB110110114114112112106106103103g/Lg/L115-115-150g/L150

4、g/LPLTPLT398398373373389389413413370370X109/LX109/L125-125-350X109/350X109/L L第6页/共17页urine routineLEULEU3+3+-UWBCUWBC44.344.3/ul/ul0-23/ul0-23/ulURBCURBC8.48.4/ul/ul0-18/ul0-18/ulECEC4.84.8/ul/ul0-3/ul0-3/ulBXBGBSYBXBGBSY8 8/HPF/HPF0-50-5个个/HP/HPHXBGBSYHXBGBSY1.51.5/HPF/HPF0-30-3个个/HPF/HPF4/21第7页/共

5、17页coagulation functionPTPT15.315.3s s10-14s10-14sINRINR1.331.33APTTAPTT37.937.9s s23-35s23-35sTTTT18.218.2s s14-21s14-21sFBGFBG3.723.72g/Lg/L1.7-4.5g/L1.7-4.5g/L第8页/共17页Liver function test4/21TPTP67.567.5g/Lg/L65-85g/L65-85g/LALBALB34.134.1g/Lg/L40-55g/L40-55g/LALPALP51.851.8U/LU/L35-100U/L35-100U/

6、LGGTGGT23.223.2U/LU/L7-45U/L7-45U/LALTALT6.96.9U/LU/L7-40U/L7-40U/LASTAST1212U/LU/L13-35U/L13-35U/L第9页/共17页Tumor marker4/7AFPAFP11.211.2ng/mlng/ml0.89-8.78ng/ml0.89-8.78ng/mlCEACEA0.480.48ng/mlng/ml0-10ng/ml0-10ng/mlCA125CA12522.122.1U/mLU/mL0-35U/mL0-35U/mLCA153CA1535.55.5U/mLU/mL0-28U/mL0-28U/mLCA

7、199CA1997.57.5U/mLU/mL0-37U/mL0-37U/mL第10页/共17页LAB FINDINGSI Imageological examinationmageological examination:1 1、肝胆胰脾、双肾输尿管、膀胱、子宫、附件无殊。2 2、右下腹非均质性包块。ESRESR2424mm/hmm/h 0-20mm/h0-20mm/h第11页/共17页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

8、后改变，周围见多个稍大淋巴结，增强明显强化。第12页/共17页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。第13页/共17页第14页/共17页Diagnosis1.1.appendicitis after appendicitis after appendectomyappendectomy2.Abdominal Abscess2.Abdominal Abscess第15页/共17页Discusion：further treatment?第16页/共17页感谢您的观看！第17页/共17页