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发布者:鑫达医学翻译 发布时间:2013-03-20 8:50:52 阅读:

原文:
现病史:2010年5月4日无明显诱因出现气短,无胸痛,无发热、咳嗽、咳痰,不能平卧,双下肢轻度可凹性水肿,就诊外院,行胸片示左侧胸腔积液。5月9日行胸部CT:左侧大量胸腔积液,伴左肺不张,右肺少许炎症,伴纤维索条影,右肺小结节。行胸腔穿刺,抽取血性胸腔积液450mL。抽取胸腔积液后气短有所缓解。此后反复行胸腔穿刺抽胸水,4次胸水涂片:大量红细胞,未见肿瘤细胞。5月16日行PE'C/CT:左侧胸膜多发软组织占位伴大量胸腔积液,FDG代谢异常增高,考虑恶性胸膜间皮瘤;大脑镰钙斑,左侧上领窦囊肿,肝左叶小囊肿,腰4-5间盘膨出伴钙化。5月18日行胸腔穿刺置管引流,每日可引出血性胸腔积液600-1000mL。5月23日行胸部增强CT(自阅片):左侧大量胸腔积液,左侧胸膜多发软组织影,左肺不张。

译文:
Present history: The patient reported short breath with unknown reasons on May 4th, 2010. No chest pain, fever, cough and expectoration were noted. Slight pitting edema was observed in the lower extremities. Pleural effusion was identified in the left lung after chest computed tomography (CT) performed in a local hospital. On June 9th, chest CT indicated a large amount of pleural effusion in the left lung together with pulmonary atelectasis in the left lobe. Additionally, slight inflammation together with strand-like shadow and nodule were identified in the right lung. Thoracentesis was performed accordingly, based on which about 450 ml sanguineous pleural effusion was extracted. After that, the patient showed relief in the short breath. Subsequently, repetitive thoracentesis was performed to extract the pleural effusion. No tumor cells were noted in the smear of hydrothorax at that time (smear of hydrothorax was performed for 4 repeats). Positron emission tomography - computed tomography (PET-CT) was performed on May 16th, 2010 which indicated multiple soft tissue lesion in the left pleura combined with a large amount of pleural effusion. In addition, enhanced metabolic disorder of fluorodexocyglucose (FDG) was observed, which may indicate the malignant pleural mesothelioma. Calcification of flax was observed. Maxillary cyst was observed in the left upper mandible. Cyst was noted in the left liver lobe. The patient received thoracentesis on May 18th, 2010 again. After that, about 600~1000 ml pleural effusion was extracted. Five days later, enhanced chest CT was performed, which indicated pleural effusion in the left thoracic cavity together with multiple soft tissue lesion in the left pleura and atelectasis of the left lung.


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