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病历翻译样例

发布者:鑫达医学翻译 发布时间:2012-11-08阅读:

The patient reported persistent angina in the right upper abdomen prior to the admission. The pain lasted for 16 hours and was induced without significant causes. Also, he showed nausea, shiver, fever, and vomit (50 ml of stomach content was observed). Abdominal and pelvic computed tomography was performed in the Department of Emergency. The scanning results indicated dilatations of intrahepatic duct and common bile-duct. Additionally, suspicious calculus region was noted in the inferior common bile duct. Abnormality was noted in hemogram. Thus, further biochemistry analysis was performed, which indicated obstructive jaundice. The patient was admitted to our department due to suspicious acute cholangitis. During the pathogenesis, no food intake was reported by the patient. He showed satisfactory sleeping habits. The urine was in a yellow color. The urinary output was normal. He denied histories of diabetes, coronary heart disease, hepatitis, tubercle, typhoid fever, allergy, swelling, trauma, smoking and alcohol intake. No genetic disease was identified among his family members.

For the physical examination, tenderness was noted in the right upper abdomen. No rebound tenderness was reported. Percussion pain was reported in hepatic region. No percussion pain on kidney region was noted. No shifting dullness was observed. Bowel sound was 3-5 times per minute. Abdominal and pelvic computed tomography indicated pneumobilia, dilatations of intrahepatic duct and common bile-duct, suspicious calculus in the inferior common bile duct, and changes in intestinal tract near the head of pancreas.


 


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