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病历诊断书:中译英-腹痛

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中文原文

患者XXX,男,30岁,以腹痛一天为主诉入院。今日就诊我院门诊,测血压180/100 mmhg,查血常规:白细胞总数12.3 10^9/L,嗜中性粒细胞比例90.8%,血淀粉酶36 U/L.腹部正位片无异常,肝胆脾胰,双肾彩超提示脾稍大,余未发现明显异常,考虑“急性肠胃炎”,予“6542”解痉后以“腹痛待查”收住院。既往有血压偏高史,位诊治。入院查体:体温:36.8℃ 脉搏60次/分 呼吸:18次/分 血压:152/100 mmHg。 神志清楚,急性痛苦面容,浅表淋巴结未触及肿大。双肺呼吸音清,未闻及干、湿性罗音:HR60 次/分,律齐,各瓣膜区未闻及杂音,未闻及心包摩擦音。腹平坦,全腹软,剑突下,脐周,右下腹麦氏点均有压痛,麦氏点压痛为主,无反跳痛,未扪及包块,肝,脾肋缘下未触及,肠鸣音4次/分,未闻及气过水音及血管杂音,振水音阴性。入院初步症断:1 ,腹痛待查:急性阑尾炎可能 2, 高血压可能。入院后查心肌酶,肾功能,电解质,复查血淀粉美无明显异常,随机血糖 70mmol/l。心电图提示窦性心动过缓,阑尾B超未见异常。予抗感染、保护胃肠粘膜,补液支持,解痉等处理,请普外科XXX副主任医师会诊考虑急性阑尾炎可能性打,进一步查腹部MRI 口头报告阑尾周边积液。米钱诊断仍考虑急性阑尾炎可能性打,与患者沟通后患者已同意行阑尾切除术。目前正安排手术治疗(阑尾切除术)。
值班医生: XXX

English translation

The patient, XXX, male, 30 years old, was hospitalized with main complaint of  “Abdomen pain for 1 day”. Today, he came to the hospital for outpatient service. The measured BP is 180/100mmHg, routine blood test result: WBC 12.3 10^9/L; neutrophil percentage 90.8%; AMY 36U/L; no abnormality in normal position film of abdomen; color doppler ultrasound prompts a lilttle big of Liver,Bladder, Spleen and Pancreas as well as both kidneys, without any abnormality found in other places. “Acute gastro enterritis” is considered. After spasmolysis treatment, the patient was hospitalized for further examination of abdomen pain. The patient has high blood pressure history, but has not received any treatment. PE after hospitalized: physical temperature: 36.8℃, pulse 60 times/min.; respiration: 18 times/min., BP: 152/100mmHg. Clear minded, acute pain expressions, no swelling of superficial lymph node is touched. Clear respiratory sound of both lungs; no dry or wet rale is heard; HR 60 beats/min., good rhythm, no noise is heard in various valve areas; no pericardial friction sound is heard, bland abdomen, full abdomen soft; tenderness under ensisternum, around navel, and McBurney point of right lower abdomen; liver, spleen and rib cage not palpable, intestinal bowel sound 4 times/min; no gurgling sound and vascular murmur is heard; succussion splash negative. Prelimanry diagnosis after hospitalized: 1. abdomen pain to be examined: possible acute appendicitis; 2. possible hyper tension. After hospitalized, AMY, kidney function, eletrolysis are examined; and AMY of blood is reexamined, no abnormality is found. Random blood sugar, 7.0 mmol/l. ECG prompts sinus bradycardia, no abnormality from X-Ray of appendix. Anti-infection, gastrointestinal mucosa protection, injection support and spasmolysis etc. are given. The deputy director doctor XXX of general surgery department was invited for the consultation, and acute appendicitis is considered with high possibility. After communication with the patient, he agreed to adopt appendectomy. Now, preparations are made for the operation (appendectomy).

Doctor on duty: XXX

 

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