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医学病例讨论,急求~英语翻译~,在线等!

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解决时间 2021-01-29 00:17
主诉:间断右下腹痛一年余
现病史:患者于2009年12月在进食辛辣、寒凉等食物后出现右下腹疼痛,呈绞痛,牵扯至脐周痛,持续2-5分钟后或俯卧位时症状缓解。自诉疼痛时可触及右下腹包快,伴有腹胀、里急后重感,有恶心,无呕吐,无发热、头晕及头痛,无显著盗汗、体重下降,未系统诊治。
既往史:既往有接触肺结核患者病史,2009年行剖宫产术。
查体:体温36.4度,脉搏78次/分,呼吸18次/分,血压128/86mmHg,双肺呼吸音清,未闻及干湿性罗音及胸膜摩擦音,心律齐,各瓣膜听诊区未闻及杂音,腹平坦,无腹壁静脉曲张,下腹正中有一长约10cm的横行手术瘢痕,腹部柔软,右下腹轻度压痛,无反跳痛,右下腹似可触及条形包块,无明显边界,无移动性浊音,肠鸣音正常,4次/分。
辅助检查:2011年2月18日丰台医院行肠镜检查示:升结肠病变性质待查。病理示:升结肠粘膜息肉样增生,另见炎性坏死组织,复合溃疡存在。我院病理会诊示:升结肠粘膜慢性炎伴糜烂溃疡,未见肿瘤。2011年3月1日我院腹部CT检查示:右肾结石,盲肠管壁增厚。血沉、结核三项正常,大便未查到结核杆菌。
最佳答案
因为本人是医学院的学生,所以对于医学专业术语较为了解。 希望可以帮到你!!!
Chief Complaint: intermittent right lower abdominal pain for over a year
History of present illness: The patient in December 2009 in the consumption of spicy, cold and other food after a right lower abdominal pain, was colic, the pain involved to Cullen, lasting 2-5 minutes, or prone position remission. Private prosecution can reach the right lower quadrant pain package quickly, accompanied by abdominal distension, tenesmus sensation, nausea, no vomiting, no fever, dizziness and headache, with no significant night sweats, weight loss, no system of treatment.
Past medical history: a history of previous contact with TB patients in 2009, cesarean section.
Physical examination: body temperature of 36.4 degrees, pulse 78 beats / min, breathing 18 times / min, blood pressure 128/86mmHg, breath sounds clear lungs, no smell and the wet and dry rales, and pleural friction of tone, rhythm together, did not hear the valve auscultation area and noise, abdomen flat, non-abdominal varicose veins, the middle lower abdomen with a transverse surgical scar 10cm long, soft abdomen, mild right lower quadrant tenderness without rebound tenderness, right lower quadrant mass may wish to touch bar, no borders, No shifting dullness, bowel sounds normal, 4 times / min.
Secondary inspection: February 18, 2011 Fengtai Hospital of colonoscopy said: ascending colon lesions of unknown origin. Pathology showed: l colonic polypoid hyperplasia, see also inflammatory necrotic tissue, combined ulcers exist. Pathology consultation in our hospital said: l chronic inflammation with erosive colonic ulcers, no tumor. March 1, 2011 in our hospital abdominal CT examination showed: right kidney, cecal wall thickening. ESR, Tuberculosis three normal bowel movements is not found in Mycobacterium tuberculosis.
全部回答
C.c. : intermittent right lower abdominal pain over a year The hpi: patients in December 2009, during eating spicy, cold food such as appears after the right lower quadrant abdominal pain, show colic involved to periumbilical pain, lasts 2-5 minutes or prone position when the symptom relief. Private prosecution right lower quadrant abdominal pain when palpable bag with abdominal distention, tenesmus fast, sense, a disgusting, vomiting, no no fever, headache, dizzy and no significant night sweats, weight loss, not system treatment. Past medical history: a prior contact phthisical patient history, 2009 underwent cesarean section. On examination, temperature 36.4 degrees, pulse 78 times/points, breathing 18 times/cent, blood pressure 128/86mmHg, double lung breath sounds clear, not smell and dry wet sex detect rales and pleural rubs, the rhythm qi, each valve auscultation area without murmurs, abdominal plain, without abdominal wall varicosity, ventral midline has a long about 10cm of surgical scar, abdominal soft hooliganism, right lower quadrant abdominal pain, no rebounded slightly tenderness, like right lower quadrant abdominal palpable bar bag piece, without obvious boundary, without mobility consonant sound is normal, and a satisfactory 4 times per minute. Auxiliary examination: 2011 February 18, fengtai hospital do endoscopic check shows: the ascending colon lesions nature referred. Pathological shows: the ascending colon mucosal polypoid, another saw inflammatory necrotic tissue composite ulcer exist. Our pathology consultation demonstration: the ascending colon mucosal chronic inflammatory companion debaucjed ulcer, did not see the tumor. 2011 on March 1 tifert abdominal CT examination reealed: the right kidney stones, caecum wall thickening. XieChen, tuberculosis three normal, defecate not checked n/med tuberculosis bacili.
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