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入院记录与出院小结翻译样例

发布者:鑫达医学翻译 发布时间:2016-10-30阅读:

原文:
现病史:患者为26岁女性,主诉外阴肿物11月。2014年3月开始出现右侧小阴唇瘙痒,最终出现“花生米大小粉色”肿块,实质,偶有破裂,伴有实性物质。肿物不断长大,患者自行用药克霉唑、氢化可的松乳膏和新孢霉素,均未见效,并最终于2015年1月15日就医。肿物于2015年1月16日由患者的初级护理医师(PCP)在诊室内切除,病理示:痣样恶性黑色素瘤,Clark等级IV,深度3 mm。PCP将上述结果告知患者,并推荐到我们诊室就诊。发病以来,患者体重未有明显变化,右侧腹股沟存在数个结节性红斑。此外,左髋有一小型皮下肿块,该肿块在外阴肿块出现前就存在,大小一直未变。

 

患者于2015年2月6日在我诊所进行病情评价,在此期间我们浏览了活检结果。检查发现,患者右侧小范围腹股沟淋巴结病,行MRI及PET/CT扫描以确定病灶范围。PET示:病灶未转移。颈部淋巴结轻度代谢增强,考虑炎症;左耳病变,炎症可能。MRI未见淋巴结病。左臀病灶约1 cm,无增强。患者行双侧前哨淋巴结活检、右侧外阴根治术、左臀及左耳病灶切除术。手术顺利,失血量约50 ml。

 

译文:

HISTORY OF PRESENT ILLNESS:

The patient was 26 year old girl who reports an 11 month history of a vulvar mass. She reports itching on her right labia minora starting March 2014 with ultimate growth of a "peanut-sized fresh pink" bump that was solid and occasionally ruptured with expression of solid material. The mass grew, and she attempted clotrimazole, hydrocortisone cream, and neosporin without success. She ultimately sought medical care on January 15, 2015. It was excised in-office by her PCP on January 16, 2015 with pathology revealing malignant melanoma, nevoid type, Clark level IV to depth of 3mm. She was notified of these findings by her PCP and referred to our office. The patient reports no changes in weight, some right inguinal bumps, and a small subcutaneous bump on her left hip that she says has been present since prior to the vulvar mass but is not growing in size. 

 

The patient was evaluated in our clinic on February 6, 2015 during which the results of her office biopsy was reviewed. On exam patient had small right inguinal lymphadenopathy for which she was sent for an MRI and PET/CT scan to determine the extent of this lesion. She also had a PET scan that showed no evidence of metastatic disease. There were mildly hypermetabolic lymph nodes in the neck that are thought to be inflammatory and a left ear lesion that may be inflammatory in origin. MRI shows no lymphadenopathy. The left gluteal lesion is about 1 cm, but non-enhancing. Patient underwent an uncomplicated bilateral sentinel lymph node biopsies, radical right vulvectomy, left buttock and left ear lesion removal. Procedure was uncomplicated with an EBL of 50 mL.

 

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