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病历翻译-肾病现病史翻译(二)

发布者:鑫达医学翻译 发布时间:2013-05-17 8:50:52 阅读:

原文:
外院予抗生素(具体不详)抗感染治疗,患者未规律服药。后于2012-11-14为行进一步检查至我院门诊就医,查IgA 3. 93g/L, IgG、IgM、C3、C4均正常,自身免疫抗体全套、抗中性粒细胞胞浆抗体均为阴性,尿红细胞相位提示:红细胞数10-15/HP,约30%基本正常;约10%轻度不等、轻度变形;约60%大小不等,见颗粒管型:(0-1/LP,粗颗粒管型。24小时尿蛋白定量2.97g/24h (尿量1500ml),B超示:右肾9.72*4.0*2.9cm,肾实质厚度1.37cm。左肾10.5*4.7*3.6cm,肾实质厚度 1.42cm,双肾实质回声增强。提示右肾略缩小,实质稍薄。测血压140/90nmHg,目前规律口服络活喜5mg每日一次降压治疗。现为求进一步诊治,拟诊“慢性肾炎综合征”收治入院。患者病程中无咳嗽咯痰咯血,无关节痛及口腔溃疡,无光过敏及皮疹,无听力及视力下降,无脱发及手足麻木感,睡眠饮食可,大便正常,尿量正常,无夜尿增多,近期体重未见明显变化。

译文:
An antibiotic (no details available) was prescribed for anti-infection, but the patient did not take it regularly. Then the patient visited the OPD of our hospital for further examination on November 14, 2012. The IgA was in a concentration of 3.93g/L. The levels of IgG, IgM, C3 and C4 were all in a normal range. Full set of autoimmune antibody examination and antineutrophil cytoplasmic antibodies were all negative. Phase contrast microscopic examination of urinary erythrocytes suggested that RBC count was 10-15/HP (about 30% basically normal, about 10% mildly unequal and mildly deformed, and about 60% unequal in size and granular casts). Quantitative test indicated the 24h urine protein was 2.97g/24h (with a urine volume of 1500ml). Ultrasonography showed: the right kidney was 9.72*4.0*2.9cm in size, and the thickness of the renal parenchyma was 1.37cm. The left kidney was 10.5*4.7*3.6cm in size, and the thickness of the renal parenchyma was 1.42cm. The echoes of both renal parenchyma were enhanced. It suggested that the right kidney was slightly decreased in size and the parenchyma slightly decreased in thickness. The blood pressure was 140/90mmHg, and the patient regularly orally took Norvasc (5mg, qd) to release blood pressure. The patient was admitted with a primary diagnosis of chronic nephritic syndrome. During the course of disease, no cough, stethocatharsis, hemoptysis, arthralgia, mouth ulcer, light sensitiveness, rash, impaired audition or vision, alopecia or deadlimb were reported. The sleep and diet were acceptable. The defecation and urine volume normal. No increase in nocturia was complained and no significant body weight change was observed recently.


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