（优质医学）英文病例汇报模板.ppt

CASE REPORT * Medical Records for Admission Name： Sex: female Age: 31 Registration No.: Date of admission： * Chief compliant Two months after appendicectomy； Recurrent abdominal pain associated 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 month maximum body temperature up to 38.9℃ * There are no similar diseases in his family Family History * right low abdominal pains tenderness（+）、Rebound tenderness（+）; Physical Examination * Blood routine * urine routine 4/21 * coagulation function * 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、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. appendicitis after appendectomy 2. Abdominal Abscess * Discusion： further treatment? *