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病历翻译作品展示

发布者:鑫达医学翻译 发布时间:2012-12-03阅读:

Present history: The patient reported short breath with unknown reasons on June 6th, 2012. 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 11th, 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).

For further examination, positron emission tomography - computed tomography (PET-CT) was performed on June 18th, 2012 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 June 20th, 2012 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. For further treatment, the patient was admitted to the Department of Respiratory Medicine in our hospital.


 


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