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发布者:鑫达医学翻译 发布时间:2013-03-21 8:50:52 阅读:

原文:
完善MRCP检查后主要诊断:胆总管结石,肝内胆管结石,肝左外侧肝内胆管结石较多,伴胆管扩张,右肝内胆管可见约3个小结石;2010年4月6日在全麻下行肝左外叶切除+胆总管切开取石+胆畅Roux-en-Y吻合+术中胆道镜检查术。
 

患者无畏寒、发热,无恶心、呕吐,饮食睡眠正常,大小便正常。查体:全身皮肤及巩膜无明显黄染,颈静脉无怒张,双肺呼吸音稍粗,未闻及明显湿性啰音;心率74次/分,律齐,未闻及早搏及病理性杂音,腹部切口已愈合;腹软,无压痛及反跳痛,肝脾肋下未及,肝肾区无叩痛,肠鸣音正常,双下肢无水肿。



 

译文:
Magnetic resonance cholangiopancreatography (MRCP) was performed, which demonstrated calculus of common bile duct, calculus of intrahepatic duct, cholangiectasis, and 3 calculi in the right intrahepatic bile ducts. For the surgery, the patient received hepatic left lateral lobectomy, choledocholithotomy, cholangio-jejunal Roux-en-Y anastomosis, and choledochoscopic examination.
 

No shiver, fever, nausea, and vomit were reported. No abnormalities were identified in the eating and sleeping habits, and defecation. For the physical examination, no significant stained yellow was noted in skin and sclera. No jugular vein distention was observed. No significant moist rale was noted in the lungs. Mild coarse breath sounds was identified in lungs. Heart rate was 74 per minute. No premature beat and pathologic murmur was identified. Satistory wound healing was obtained. No tenderness and rebound tenderness was identified. No percussion pain was noted in liver and kidney. The bowel sounds were normal. No swelling was noted in lower extremities.


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