醫(yī)學(xué)診斷翻譯-病歷診斷書翻譯-醫(yī)學(xué)病例翻譯
中文原文
患者XXX，男，30歲，以腹痛一天為主訴入院。今日就診我院門診，測(cè)血壓180/100 mmhg,查血常規(guī)：白細(xì)胞總數(shù)12.3 10^9/L,嗜中性粒細(xì)胞比例90.8%，血淀粉酶36 U/L.腹部正位片無(wú)異常，肝膽脾胰，雙腎彩超提示脾稍大，余未發(fā)現(xiàn)明顯異常，考慮“急性腸胃炎”，予“6542”解痙后以“腹痛待查”收住院。既往有血壓偏高史，位診治。入院查體：體溫：36.8℃ 脈搏60次/分 呼吸：18次/分 血壓：152/100 mmHg。 神志清楚，急性痛苦面容，淺表淋巴結(jié)未觸及腫大。雙肺呼吸音清，未聞及干、濕性羅音：HR60 次/分，律齊，各瓣膜區(qū)未聞及雜音，未聞及心包摩擦音。腹平坦，全腹軟，劍突下，臍周，右下腹麥?zhǔn)宵c(diǎn)均有壓痛，麥?zhǔn)宵c(diǎn)壓痛為主，無(wú)反跳痛，未捫及包塊，肝，脾肋緣下未觸及，腸鳴音4次/分，未聞及氣過(guò)水音及血管雜音，振水音陰性。入院初步癥斷：1 ，腹痛待查：急性闌尾炎可能 2， 高血壓可能。入院后查心肌酶，腎功能，電解質(zhì)，復(fù)查血淀粉美無(wú)明顯異常，隨機(jī)血糖 70mmol/l。心電圖提示竇性心動(dòng)過(guò)緩，闌尾B超未見(jiàn)異常。予抗感染、保護(hù)胃腸粘膜，補(bǔ)液支持，解痙等處理，請(qǐng)普外科XXX副主任醫(yī)師會(huì)診考慮急性闌尾炎可能性打，進(jìn)一步查腹部MRI 口頭報(bào)告闌尾周邊積液。米錢診斷仍考慮急性闌尾炎可能性打，與患者溝通后患者已同意行闌尾切除術(shù)。目前正安排手術(shù)治療（闌尾切除術(shù)）。
值班醫(yī)生： XXX
English translation
The patient, XXX, male, 30 years old, was hospitalized with main complaint of ”Abdomen pain for 1 day”. Today, he came to the hospital for outpatient service. The measured BP is 180/100mmHg, routine blood test result: WBC 12.3 10^9/L; neutrophil percentage 90.8%; AMY 36U/L; no abnormality in normal position film of abdomen; color doppler ultrasound prompts a lilttle big of Liver,Bladder, Spleen and Pancreas as well as both kidneys, without any abnormality found in other places. “Acute gastro enterritis” is considered. After spasmolysis treatment, the patient was hospitalized for further examination of abdomen pain. The patient has high blood pressure history, but has not received any treatment. PE after hospitalized: physical temperature: 36.8℃, pulse 60 times/min.; respiration: 18 times/min., BP: 152/100mmHg. Clear minded, acute pain expressions, no swelling of superficial lymph node is touched. Clear respiratory sound of both lungs; no dry or wet rale is heard; HR 60 beats/min., good rhythm, no noise is heard in various valve areas; no pericardial friction sound is heard, bland abdomen, full abdomen soft; tenderness under ensisternum, around navel, and McBurney point of right lower abdomen; liver, spleen and rib cage not palpable, intestinal bowel sound 4 times/min; no gurgling sound and vascular murmur is heard; succussion splash negative. Prelimanry diagnosis after hospitalized: 1. abdomen pain to be examined: possible acute appendicitis; 2. possible hyper tension. After hospitalized, AMY, kidney function, eletrolysis are examined; and AMY of blood is reexamined, no abnormality is found. Random blood sugar, 7.0 mmol/l. ECG prompts sinus bradycardia, no abnormality from X-Ray of appendix. Anti-infection, gastrointestinal mucosa protection, injection support and spasmolysis etc. are given. The deputy director doctor XXX of general surgery department was invited for the consultation, and acute appendicitis is considered with high possibility. After communication with the patient, he agreed to adopt appendectomy. Now, preparations are made for the operation (appendectomy).
Doctor on duty: XXX
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