出国看病
病历翻译

上海医学翻译中心 021-51036356

病历翻译样例

不少患者家属找我们翻译病历的时候,希望我们可以提供以前翻译的病历、CT报告、病理报告等,查看翻译质量。不过我们确实无法提供以前翻译的病历。因为他人的病史资料都是属于个人隐私,没法给无关第三方查看。

鉴于很多患者家属提出了这种要求,我们从网上找到了公开的病历进行试译,供参考翻译质量。

Carousel imageCarousel imageCarousel imageCarousel image

中译英病历翻译样例

  • 以下这段病理报告来源于公开来源:中华医学会病理学分会第二十一次学术会议暨第五届中国病理年会 - 读片会

https://med.motic.com/seminar/index.html

病史:患者,男,17岁,以“体检发现腹膜后肿物3天”为主诉入院。全腹彩超:腹膜后混合性回声区(囊性为主),与右肾中上段、右肝关系密切,考虑来源于右肾可能性大;肝、胆、胰、脾未见明显异常;门静脉血流显像好。中上腹部磁共振平扫+增强:右侧上中腹部巨大占位,考虑来源于右肾-囊性肾癌。大体:右肾:大小25*19*10cm,切面见肿物呈囊性,大小为7*5*4.0cm,囊内容物血性液体,肿物囊壁部分见钙化,实性部分呈灰白、灰红,质地脆,周围残余少量正常肾组织,肾门未见明显淋巴结。右肾上腺:组织一块,大小5*3*2.5cm,切面呈囊实性、暗褐色。右腹膜后淋巴结:找到淋巴结4枚。

MEDICAL HISTORY: The patient is a 17 years old male. He was admitted to our hospital with the chief complaint “A retroperitoneal mass was found on physical examination at 3 days ago". Complete abdominal ultrasound using color Doppler: A mixed echogenic (mainly cystic) zone was found at the retroperitoneal region. It was very close to upper third & middle third of the right kidney, and the right lobe of liver. This mass was probably originated from right kidney. The liver, gallbladder, pancreas, and spleen did not show obvious abnormalities. Blood flow in the portal vein could be clearly seen. Unenhanced + Enhanced MRI scan of middle - upper abdomen: A huge space-occupying mass was found at the right sided middle - upper abdomen, it was considered as a cystic carcinoma of right kidney. Gross pathology: Right kidney: 25*19*10cm in size. Its cut surface showed a cystic mass with the size of 7*5*4.0cm. The cystic mass was full of bloody fluid, the cystic wall was partially calcified. The solid part of the cystic mass was gray and gray-red, with crisp texture. A small amount of normal residual renal tissue was found around the mass. There was no obvious lymph node at the right renal hilum. Right adrenal gland: It was a tissue with the size of 5*3*2.5cm, its cut surface was cystic-solid, dark brown in color. Right retroperitoneal lymph nodes: Found 4 lymph nodes.

  • 以下这段入院报告节选来源于公开来源:奥林巴斯华东消化学院疑难病例讨论会第三季ERCP篇

https://www.sohu.com/a/446071120_650879

女,60岁,间断上腹痛一月余,再发伴加重4天

一月余前无明显诱因下出现上腹疼痛,当地医院查MRCP提示肝内外胆管结石,予“抗感染”等对症治疗,症状缓解

入院前4天(2020年2月25日)再发上腹痛,程度较一月前加剧,至当地医院就诊,考虑急性胰腺炎、肝内外胆管结石。给予对症治疗,症状未缓解,遂至我院急诊。期间患者间断便血

既往史:20余年前先后胆囊切除、胆管切开取石术

A 60-year-old lady presented with intermittent epigastric pain for more than one month and recurrence with aggravation for 4 days.

She developed epigastric pain without obvious inducements at more than 1 month ago. MRCP test in a local hospital revealed intrahepatic and extrahepatic bile duct stones. After the patient was given “anti-infectives" and other symptomatic treatment, the symptoms were relieved.

On Feb 25, 2020 (4 days before admission), the epigastric pain recurred, which was more severe compared with that of a month ago. She visited a local hospital and was considered to have acute pancreatitis and intrahepatic and extrahepatic bile duct stones. Her symptoms did not alleviate after symptomatic treatment, so she visited the emergency department of our hospital. The patient had intermittent hematochezia during this period.

Past history: She underwent cholecystectomy and choledocholithotomy successively more than 20 years ago.


  • 以下这段检查报告来源于公开来源,北医三院的病例讨论

http://www.puh3.net.cn/hxnk/bltl/19276.shtml

查体:Bp150/100mmhg,浅表淋巴结未及肿大,双肺呼吸音清,未闻及干湿性罗音,心律齐,未闻及杂音,腹软,无压痛,双下肢无水肿。

初步诊断:纵膈淋巴结肿大待查

腹部CT:肝内多发病变,性质待定,脓肿,转移瘤?必要时MRI,腹膜后多发小淋巴结。B超示双锁骨上及双颈部多发淋巴结(结构大致正常)。

Physical Examination: BP: 150/100 mmHg. No swollen superficial lymph nodes were found by palpation. Breath sounds in both lungs were normal and clear, without moist or dry rales. His heart rhythm was regular, without heart murmur. His abdomen was soft, without tenderness. Both lower extremities were without edema.

Initial diagnosis: Mediastinal lymph node enlargement, to be investigated.

Abdominal CT: Multiple intrahepatic lesions, to be investigated. Abscess? Metastases? If necessary, MRI can be performed. Multiple retroperitoneal small lymph nodes were found. B-scan ultrasonography showed multiple lymph nodes in bilateral supraclavicular and bilateral neck region (the structures of these lymph nodes were generally normal).

  • 以下这段入院报告节选也来源于公开来源:中华医学会病理学分会第二十一次学术会议暨第五届中国病理年会 - 读片会

https://med.motic.com/seminar/index.html

体检发现盆腔包块4天入院。妇科检查:子宫后方扪及12×10cm大小包块,质中,活动度欠佳,无压痛。CT检查:盆腔及子宫后方巨大囊实性肿块。2014年4月1日全麻下行剖腹探查及肿块切除术,术中见子宫右后方腹膜内扪及较大囊实性肿块,约12×12×10cm,表面光滑,包膜完整,呈暗紫色,与子宫及双附件均无粘连。原单位病理诊断:倾向血管周上皮样细胞分化的肿瘤,具有高风险侵袭行为。南京某三甲医院病理科会诊结果:低分化癌,倾向低分化腺癌。

大体检查:盆腔肿块:囊性包块,大小12×9×8.5cm,局灶囊壁内见暗红色结节,大小2.5×2×0.5cm;阔韧带后叶处肿块:结节状肿块一枚,大小3.5×3.5×2.5cm。

The patient was admitted due to “a pelvic mass was found in physical examination at 4 days ago” Gynecological examination: A 12 × 10 cm sized mass was palpable behind the uterus; the mass was moderate in hardness, poor in mobility, without tenderness. CT scan: A large mixed cystic-solid mass was observed in the pelvic cavity, behind the uterus. On April 1, 2014, exploratory laparotomy and mass excision were performed under general anesthesia. During the operation, a large mixed cystic-solid mass, about 12×12×10 cm in size, was found in the peritoneum behind the uterus, at the right side of the uterus. It had a smooth surface, a complete capsule. It was in dark purple color; without adhesion to the uterus or either adnexa. Pathological diagnosis of the original hospital: favor perivascular epithelioid cell neoplasm with high-risk aggressive behavior. Consultation result of pathology department in a tertiary hospital in Nanjing City: Poorly differentiated carcinoma, favor poorly-differentiated adenocarcinoma.

Gross observation: A pelvic mass: A cystic mass, 12 × 9 × 8.5 cm in size. A dark red nodule measuring 2.5 × 2 × 0.5 cm in size were observed within its focal cyst wall. A mass at the posterior part of broad ligament: One nodular mass, 3.5 × 3.5 × 2.5 cm in size.

  • 以下这段胸壁占位病变的鉴别诊断来源于公开来源:伦琴医疗病例讨论

https://www.163.com/dy/article/GDTJDN9C05340MBN.html

主诉:反复胸闷气促2月余

现病史:患者2月初无明显诱因下出现胸闷、气促,活动后加重,休息后缓解,无心悸发热,无咳嗽咳痰。入院后查梅毒螺旋体抗体、HIV抗原抗体、自身抗体、抗中性粒细胞抗体、基地膜抗体、结核T细胞、肿瘤标志物均未见异常。胸水培养未见细菌,涂片未见癌细胞。胸水结核分枝杆菌rpoB基因检查:阴性。糖尿病、高血压病史10余年

Chief Complaint: Repeated chest tightness and shortness of breath for more than two months.

History of present illness: The patient developed chest tightness and shortness of breath without obvious inducement in early February, which were aggravated after activities and relieved after rest. The patient had no palpitation, fever, cough or expectoration. After admission, tests of Treponema antibody, HIV antibody/antigen, autoantibodies, antineutrophil antibodies, anti–glomerular basement membrane antibody, tuberculosis-specific T cells, and tumor markers showed no abnormalities. Pleural fluid culture showed no bacteria. Pleural fluid smear showed no cancer cells. Pleural fluid testing for Mycobacterium tuberculosis gene rpoB: negative. The patient has a history of diabetes and hypertension for more than 10 years.


  • 以下这段听神经瘤的病历来源于公开来源:湘南学院附属医院神经外科病例

https://www.sohu.com/a/463374415_120150976

患者女性,40岁,2年前右侧听力下降,伴耳鸣,1个月前症状逐渐加重,出现头痛、行走不稳等情况,前往湘南学院附属医院就诊。头颅MRI检查示:右侧内耳道扩大,可见囊实性结节影,脑干受压明显,诊断为右侧听神经鞘瘤。

神经外科罗忠平主任带领团队病例讨论,指出肿瘤已经压迫脑干,必须尽快手术,决定在神经电生理监测下行右侧开颅肿瘤切除术。

A 40-year-old lady presented to the Affiliated Hospital of Xiangnan University with hearing loss accompanied by tinnitus in right ear for 2 years. One month ago, these symptoms gradually worsened, she also developed headache and unstable walking. Head MRI: The right internal auditory canal was enlarged, and a mixed cystic-solid nodule with obvious compression of the brain stem was observed. The diagnosis was acoustic neuroma in the right internal auditory canal.

Director Luo Zhongping of the Department of Neurosurgery led the team to discuss the case, and pointed out that the tumor had compressed the brainstem and the operation must be carried out as soon as possible. The right-sided craniotomy for resection of acoustic neuroma with neurophysiological monitoring was scheduled.

  • 以下这段肺癌的病历来源于公开来源:浙江省肿瘤医院病例讨论

https://www.sohu.com/a/290910928_100200059

本院颅脑增强MRI:未见明显异常。

支气管镜所见:右肺下叶:管腔狭窄,黏膜浸润样改变,表面粗糙,累及中间支气管及中叶开口,咬检。(右肺下叶)病理:(右肺下叶)低分化非小细胞癌(倾向腺癌)。IHC:CK(+)、NapsinA(+)、TTF1(+)、ALK(D5F3)(+)。

分子检测:EGFR基因(ARMS)未检测到突变。

右肝肿块穿刺病理:腺癌。IHC:ALK(D5F3)(+)、ALK-NC(-)、Napsin A(+)、TTF1(+)、CK7(+)、SP-A(+)。

骨ECT影像(2016-2-16):全身多处骨代谢活跃,提示广泛骨转移。可见颅骨、胸骨、全身肋骨、肩胛骨、颈胸腰椎椎体、骨盆多处、四肢长骨等有多处大小不等形态各异的放射性浓聚影。双肾显影。

Contrast enhanced MRI of the brain in our hospital: No obvious abnormality was found.

Bronchoscopic findings: Right lower lobe of the lung: Bronchial stenosis; infiltrative changes and rough surface of the mucosa; involving the openings of the intermediate bronchus and middle lobe bronchus. Bite biopsy was performed in this region. (Right lower lobe) Pathology: (Right lower lobe) poorly differentiated carcinoma (favor adenocarcinoma). IHC: CK (+), NapsinA (+), TTF1 (+), ALK (D5F3) (+).

Molecular testing: No mutations were detected in the EGFR gene (Super-ARMS® EGFR kit).

Fine needle biopsy pathology of right liver mass: Adenocarcinoma. IHC: ALK (D5F3) (+), ALK-NC (-), Napsin A (+), TTF1 (+), CK7 (+), SP-A (+).

Whole-body bone scan by emission CT (February 16, 2016): The patient had active bone metabolism in multiple places throughout the body, suggesting extensive bone metastases. Multiple radiotracer-avid foci of varying sizes and morphologies were observed in the skull, sternum, all ribs, scapulas, cervical, thoracic and lumbar vertebrae, multiple areas of the pelvis, and long bones of the limbs. Both kidneys were visualized.

  • 贵州省人民医院病例讨论:广泛性焦虑症致肢体震颤误诊为帕金森氏病1例

患者,男, 59岁,因“双上肢不自主震颤3年”于2006年4月8日入院,患者于3年前无明显诱因出现双上肢不自主震颤,静止时明显,情绪紧张时加重,睡眠时消失,曾在多家医院做头颅CT、MRI检查未见异常,诊断为“帕金森氏病”,以“美多芭125mg, tid, Po”,症状有所控制。1周前上述症状加重,伴明显焦虑、恐慌,入我院。既往无高血压、糖尿病、心脏病史。适龄结婚,育有1女, 4年前因车祸去世,爱人健康。体检:生命体征平稳,BP 110 /70mmHg,神清语利,定时定向力完整,问答切题,有时显紧张焦虑,双上肢静止震颤。行走转身自如,步态姿势正常,四肢灵活,肌张力不高,无齿轮样或折刀样、铅管样改变。心、肺、腹( - ) ;神经系统( - ) ;头颅CT、MR I( - ) ;血常规、生化( - ) 。入院后仍诊为帕金森氏病,但治疗效果欠佳。治疗或医患沟通病情时,患者四肢震颤、恐慌明显加重,有幻觉,肢体僵硬,谨小慎微,常觉“自己将遭遇极大不幸”。追问病史患者于入院前2年其父不幸突然病逝,患者受精神打击较大,自觉亲情失落,数日难以入睡。据此诊为广泛性焦虑症,给予心理治疗、奋乃静等处理, 1个月后基本痊愈。

The patient is a 59 years old gentleman. He was admitted due to "involuntary tremor of both upper limbs for 3 years" on April 8, 2006. He developed involuntary tremor of both upper limbs without obvious inducement 3 years ago. The tremor was evident at rest, aggravated during emotional stress, and disappeared during sleep. He had undergone head CT and MRI scan in several hospitals; no abnormal finding was found. The patient was diagnosed with "Parkinson's disease", and was given “madopar 125 mg, tid, PO", and the symptoms were relieved. One week ago, the above symptoms worsened, accompanied by significant anxiety and panic, and he was admitted to our hospital. He had no history of hypertension, diabetes mellitus or heart disease. He was married at an appropriate age and had a daughter, who died in a car accident 4 years ago. His wife is healthy. Physical examination: The patient’s vital signs were stable. BP 110/70mmHg. The patient was with clear mind and speaking. His orientation ability and ability to judge time were normal. His answers to questions were on-topic; he showed nervous and anxious sometimes. Resting tremor was found in both upper limbs. Walking and turning were normal. His gait was normal. His upper and lower limbs could move normally. His muscle tone was not high; and there was no cogwheel, clasp-knife, or lead pipe rigidity. Heart, lung and abdomen did not show any abnormal findings. Nervous System did not show any abnormal findings. The CT scan and MRI scan of the head did not show any abnormal findings. Routine blood test and blood chemistry test did not show any abnormal findings. The admission diagnosis was still Parkinson's disease, but the treatment effect was not good. During treatment or doctor-patient communication of the condition, the patient's limb tremor and panic were significantly aggravated. He had hallucinations, stiffness of the limbs, was cautious, and often felt that "great misfortune would befall him". On questioning the medical history, it was found that the patient's father died of disease suddenly 2 years before. The patient had been suffering from psychological shock and felt a loss of affection, and had difficulty sleeping for several days after his father’s death. Based on this, he was diagnosed with generalized anxiety disorder and treated with psychotherapy and perphenazine. He was basically cured after 1 month.

英译中病历翻译样例

A Pt with Abdom Pain and Vomiting

https://medicine.yale.edu/intmed/education/medstudent/intmedclerkship/student_resources/casediscussions/
A Patient with Abdominal Pain and Vomiting

A 39-year-old woman is admitted to you because of severe abdominal pain and vomiting. She states that her illness began about 3 days ago with midepigastric pain and nausea, and progressed to severe abdominal pain, nausea and vomiting. She describes her pain as crampy, without any radiation, and continuous throughout the day so that she cannot eat. She denies back pain, flank pain, diarrhea, dysuria, hematuria, cough or any similar episode of pain before. She denies eating any unusual foods, and her medications include NSAIDs for headaches, and oral contraceptives; she recently took a course of metronidazole for Trichomonas vaginitis. She is employed as a corporate vice-president, and lives with her daughter and husband. She does not smoke cigarettes and drinks alcohol only on social occasions. Her parents both died of cancer and she had a sister who committed suicide.

PE reveals a thin woman lying on her side in a fetal position. T 99, P 130, R 20, BP 100/82. SKIN - warm, dry without lesions. LN - none. HEENT - normal with dry mucosa. CHEST - clear. HEART - RRR 2/6 SEM; no rub or gallop. ABD - scaphoid with diffuse tenderness to light palpation especially in midepigastrium; voluntary guarding in all quadrants; no rebound; no organomegaly or palpable masses; BS absent. PELVIC - normal with normal rectum. Stool trace heme positive. NEURO - nonfocal.

LABS

Na 142, K 3.1, Cl 100, HCO3 36, BUN 25 Cr 1.2, glu 60

Hb 13.3, Hct 39.7, WBC 14.8 (88 segs, 10 bands, 2 lymphs)

UA – normal; ABG (RA) 7.50/38/64

AST 102; ALT 75; Alk Phos 126; LDH 140 Amylase 806; Lipase 180

EKG – Sinus tach 130/flattened T waves in V2-V6

CXR - atelectasis at both bases; small left pleural effusion
腹痛呕吐患者

患者女,39岁,因剧烈腹痛、呕吐入院。患者称其在约3天前开始出现中腹部疼痛、恶心,并进展为剧烈腹痛、恶心、呕吐。疼痛为绞痛,无放射痛,而且全天持续,因此她无法进食。她否认背痛、腰痛、腹泻、排尿困难、血尿、咳嗽、或之前发作过类似疼痛。她否认吃过异常食物,她的药物包括治疗头痛的非甾体抗炎药,以及口服避孕药;她最近因滴虫性阴道炎用了一个疗程的甲硝唑。她是一名企业副总裁,与女儿和丈夫同住。她不抽烟,只在社交场合饮酒。她的父母都死于癌症,她有一个姐姐死于自杀。

体检示,女患者身体偏瘦,蜷缩侧卧。体温 99华氏度,脉搏 130次每分,呼吸 20次每分,血压 100/82毫米汞柱。皮肤 — 温热、干燥、无病变。淋巴结 — 未及。五官 — 正常,粘膜干燥。胸部 — 无殊。心脏 — 心率平,收缩期喷射型杂音 2/6 ;无摩擦音或奔马律。腹部 — 轻压有弥漫性压痛,尤其是在腹中部;全腹所有象限都自发紧绷;无反跳痛;无器官肿大或可触及的肿块;无肠鸣音。盆腔 — 正常,直肠正常。粪便隐血阳性。神经 — 无局灶性异常

实验室检查

钠142、钾3.1、氯100、碳酸氢盐36、尿素氮25、肌酐1.2、血糖60

血红蛋白13.3、血细胞压积39.7、白细胞14.8(分叶核88%、杆状核10%、淋巴细胞2%)

尿液 — 正常;动脉血气分析(RA) 7.50/38/64

天门冬氨酸氨基转移酶102,丙氨酸氨基转移酶75,碱性磷酸酶126,乳酸脱氢酶140,淀粉酶806,脂肪酶180

心电图 — 窦性心动过速130/V2-V6T波低平

胸片 — 两肺底肺不张;左侧胸腔有少量积液


Managing Neutropenia in a Patient with Abdominal Pain Following Chemotherapy

https://www.cancertherapyadvisor.com/slideshow/clinical-quiz/a-64-year-old-man-with-a-chronic-rash/

Chief Complaint

MP is a 38-year-old woman who comes to the clinic with a temperature of 101F and complains of abdominal pain approximately 14 days after her last chemotherapy treatment.

Results of Last Visit

During her last appointment, MP denied fevers, chills, or other signs/symptoms of infection but, due to laboratory results, was initiated on levofloxacin 750 mg orally once daily as prophylactic therapy.

Relevant Medical History

• Diagnosis of triple-negative breast cancer

• Current therapies include cyclophosphamide and doxorubicin (AC) every 21 days x 4 cycles

• Ten days after receiving her last dose of chemotherapy, her complete blood cell count (CBC) results, showing neutropenia, are shown in Table/Slide 1.

化疗后腹痛患者发生中性粒细胞减少症的治疗一例

主诉

MP,女,38岁,门诊就诊时体温为101华氏度,主诉上次化疗后腹痛约14天。

上次就诊的结果

在她上次就诊时,MP否认有发热、寒战或其他的感染症状/体征,但由于有实验室结果作为依据,她开始左氧氟沙星750毫克口服,每日一次,作为预防治疗。

相关病史

三阴性乳腺癌诊断

目前的治疗包括环磷酰胺+多柔比星(AC)21 x 4个周期

在上次化疗的10天后,她的全血细胞计数(CBC)显示中性粒细胞减少,见/幻灯片1

Renal Cell Carcinoma Patient with Liver Mets

https://www.cancertherapyadvisor.com/slideshow/clinical-quiz/renal-cell-carcinoma-patient-with-liver-mets/

A 72-year-old male presents with fatigue and shortness of breath. On initial laboratory evaluation, he is found to have a hematocrit level of 55%. His past medical history is significant for hypertension, hyperlipidemia, coronary artery disease, and gastroesophageal reflux disease. Surgical history is only notable for cardiac stenting and tonsillectomy. He underwent contrast-enhanced CT, which revealed a large right renal mass with tumor thrombus extension into the renal vein (Slide 2) and a mass within the liver that was suspicious for a metastatic focus (Slide 3).

肾细胞癌伴肝转移患者

一名72岁男性因疲劳、呼吸短促而就诊。初步实验室检查发现他的红细胞压积水平为55%。他的既往病史包括高血压、高脂血症、冠心病和胃食管反流。手术史仅有心脏支架手术和扁桃体切除术值得注意。他接受了对比增强CT,显示右肾一个巨大肿块伴癌栓延伸至肾静脉(幻灯片2),肝内有一个肿块,考虑为转移灶(幻灯片3)

A Patient with Pleuritic Chest Pain and Dyspnea

https://medicine.yale.edu/intmed/education/medstudent/intmedclerkship/student_resources/casediscussions/


A 63-year-old woman is admitted to the hospital because of acute dyspnea and right sided chest pain. She has a long history of medical problems including hypertension, and insulin dependent DM and chronic kidney disease. She sustained an inferior-lateral wall transmural myocardial infarction 5 years ago with a residual left ventricular ejection fraction of 30%. Three years ago, she underwent a left mastectomy for breast carcinoma and completed 6 months of adjuvant chemotherapy because of tumor involvement in 3 axillary lymph nodes (hormone receptors were negative).

She had been feeling relatively well lately until the day of admission when she noted the acute onset of dyspnea in the morning. This progressed throughout the day and was associated with pain in her right chest that increased upon inspiration, so she came to the Yale Emergency Department. She denied fever, cough, headache, abdominal pain, back pain, or light headedness. Her medications include insulin, Lasix, Lopressor, and an ACE-inhibitor.

PE reveals a dyspneic obese woman. T 99.4, R 32, P 120, BP 130/84. SKIN - no rash or lesions. LN - none palpable. HEENT - conj pink; Fundi - background but no proliferative retinopathy; oropharynx benign. CHEST - clear; mastectomy scar healed. COR - RRR without murmurs or rub. ABD - obese, soft, nontender without hepatosplenomegaly. NEURO - normal. EXT – benign without edema or erythema.

LABS Na 136, K 3.0, Cl 99, HCO3 24, Cr 1.7, glu 160

Hb 14.0, Hct 42.1, WBC 12.2 (normal differential), plts 375K

UA: clear/1.016/2+ protein/2+ glucose/no ketones, cells or casts

EKG: Stach 120/ Q waves in II, III, avF, V4-6; no change from

recent EKG

CXR: clear lungs, normal heart size

ABG (room air) pH 7.52/pCO2 22/pO2 51

胸膜炎性胸痛伴呼吸困难患者

患者女,63岁,因急性呼吸困难、右侧胸痛入院。她有高血压、胰岛素依赖性糖尿病和慢性肾病的长期病史。5年前,她发生下侧壁透壁性心肌梗死,残余的左心室射血分数为30%。三年前,她因乳腺癌接受了左乳房切除术,并因发现3个腋窝淋巴结转移(激素受体为阴性)接受了6个月的辅助化疗。

她最近无不适感,但在入院当天早上出现呼吸困难急性发作。这种情况持续了一天,并伴右胸疼痛,吸气时疼痛加剧。所以她来到耶鲁急诊部就诊。患者否认发烧、咳嗽、头痛、腹痛、背痛或头晕。她目前的用药包括胰岛素、Lasix(呋塞米)、Lopressor(美托洛尔)和一种血管紧张素转化酶抑制剂。

体检:肥胖女性,呼吸困难。体温:99.4华氏度;呼吸频率:32次/分;脉搏:120次/分;血压:130/84毫米汞柱。皮肤—无皮疹或损伤。淋巴结—无可触及淋巴结。五官—结膜呈粉红色;眼底——有背景性视网膜病变但无增殖性视网膜病变;口咽部无殊。胸部—无殊;乳房部位有乳房切除后愈合疤痕。心脏听诊—心率正常,心律齐,无杂音或摩擦音。腹部—肥胖、柔软、无压痛、无肝脾肿大。神经系统—正常。四肢—无异常,无水肿或红斑。

实验室检查 钠136、钾3.0、氯99、碳酸氢盐24、肌酐1.7、血糖160

血红蛋白14.0、血细胞压积42.1、白细胞12.2(白细胞分类正常)、血小板375K

尿液:透明、比重1.016、蛋白质2+、葡萄糖2+、未检出酮体、细胞或管型

心电图:窦性心动过速,120次每分;第II、III、avF、V4-6导联见Q波;与前次心电图相比没有变化。

胸片:肺部无异常;心脏大小正常

动脉血气分析(未吸氧):pH 7.52、pCO2 22、pO2 51

A Patient with Ascites

A 52-year-old woman was admitted to the hospital because of increased abdominal girth and evidence for new onset ascites. About two months prior to admission she noted unexpected weight gain of 10 lbs. This was followed by ankle swelling when she stood up for long periods, and progressed to the point that her clothes became too tight. She said it felt like she was pregnant.

Over the course of the last two weeks she noted increased fatigue, more difficulty sleeping and dyspnea on exertion. Today she claimed that her abdomen and shoulders hurt so she sought medical attention. She has a history of alcohol abuse over the past 20 years, and was hospitalized once for pancreatitis related to alcohol, but had no history of liver disease. She denied any chest pain, cough, change in bowel habits, jaundice, vaginal or rectal bleeding. She lives with her husband and has three healthy children. She has no family history of similar problems; her parents both died of heart disease.

P.E. reveals a thin woman with protuberant abdomen in mild respiratory distress. T 99oF; P 100; R 30; BP 120/80. SKIN - normal but with scattered spider angiomata. LN - none palpable. HEENT - conjuctivae normal; FUNDI - normal; oropharynx dry without lesions. CHEST - clear with decreased breath sounds at both bases about 1/4 way up; percussion note is dull over the same area and there is an absence of tactile fremitus at both bases. COR - JVP is 6 cm; RRR with no murmurs, gallops or rubs audible. ABD - protuberant but symmetrical on inspection; there are no palpable masses; liver and spleen are not palpable; there is mild tenderness throughout but no rebound pain; flank dullness and fluid wave are evident; BS are diminished but present. G/R - speculum exam is normal; rectum is normal; stool heme negative. NEURO - nonfocal. EXTREMITIES - 2+ edema.

LABS: Na 128, K 3.2, Cl 107, HCO3 17, BUN 4, Cr 0.5, glu192

Hb 13.0, Hct 39.0, WBC 10.5 (normal differential), plts 143 K

UA: clear/1.010/1+ protein; no glucose, ketones, cells or casts

EKG: NSR 100/nl intervals/no ST-T wave changes

CXR: bilateral pleural effusions; normal heart size

一位腹水患者

患者女,52岁,因腹围增大,有新发腹水证据入院。入院前约两个月,她注意到体重意外增加10磅。随后,长时间站立时,她出现脚踝肿胀,并发展到衣服太紧的程度。她说感觉像是怀孕了。

在过去两周内,她注意到疲劳感增加、睡眠更困难和劳力性呼吸困难。今天,她因腹部和肩部疼痛就诊。她在过去20年中有酗酒史,曾因酒精相关性胰腺炎住院一次,但无肝病史。患者否认有胸痛、咳嗽、排便习惯改变、黄疸、阴道或直肠出血。她和丈夫一起生活,三子女均体健。她没有类似病情的家族史;她的父母都死于心脏病。

查体:消瘦女性,腹部突起,有轻度呼吸窘迫。体温99华氏度,脉搏100次每分,呼吸30次每分,血压120/80毫米汞柱。皮肤:正常,但有散在的蜘蛛痣。淋巴结:无可触及淋巴结。五官:结膜正常;眼底:正常;口咽部干燥,无病变。胸部:呼吸音清,两肺底约下1/4处呼吸音减弱;同一区域叩诊音钝,双侧肺底无语音震颤。心脏检查:颈静脉压(JVP):6 cm;心律齐、心率平、无杂音、奔马律或摩擦音。腹部:隆起但对称;无可触及包块;肝脾肋下未及;全腹有轻微压痛,但无反跳痛;侧腹浊音,有明显液波震颤肠鸣音减弱但存在。生殖器/直肠:窥镜检查正常;直肠正常;大便血红素阴性。神经:无局灶性异常四肢:水肿2+。

实验室检查

钠128、钾3.2、氯107、碳酸氢盐17、尿素氮4、肌酐0.5、血糖192

血红蛋白13.0、血细胞压积39.0、白细胞10.5(白细胞分类正常)、血小板143 K

尿液:澄清;1.010;蛋白质1+;无葡萄糖、酮体、细胞或管型

心电图:正常窦性心律 100次每分;各间期正常;无ST-T波改变

:双侧胸腔积液;心脏大小正常


另外插一句,很多患者及家属搞不清楚哪些检查报告、哪些手术记录需要翻译,可以参考这个网页

免责声明:以上内容仅供参考,上海医学翻译中心仅出于善意提供,如果上述内容对您或其他任何人造成任何误导、或者造成任何损失,上海医学翻译中心对此不负任何直接、间接或者连带责任。

微信扫一扫加好友联系我们: