casereportofXXX英文病例汇报.doc

Medical Records for Admisson Medical Number: General information Name: XXX Age: Twenty One Sex: Male Race: Han Nationality: China Address: XinYang,Henan. Occupation: Excavator driver Marital status: Unmarried Date of admission: Nov 11th, 2015 Date of record: 8Pm, Nov 11th, 2015 Complainer of history: patient’s father and himself Reliability: Reliable Chief complaint: Reduplicated nausea and vomit for seven months. Present illness: The patient felt sudden nausea and vomited the food he took in with no recognizable cause about seven months ago. He didn’t pay attention to it and thought he had ate something wrong. About two weeks later, the nauseous and vomitory symptom appeared again and he felt sour regurgitation and heartburn at the same time.So he went to the No.1 subsidiary hospital of Su Zhou University. The endoscopic examination showed he had duodenal ulcers and reflux esophagitis.And the pathological report of the ulcers was chronic inflammation with proliferation of lymphocytes.Then the Rabeprazole which had show a curative effect was given to him.But two months later after the treatment,the above-mentioned symptom appeared again and became more serious and he went to the No.1 subsidiary hospital of Su Zhou University again for threatment.The abdominal CT,MRI and MRCP all showed the dilatation of the bile ducts（both the intrahepatic and extrahepatic bile ducts）and the pancreiatic ducts.Besides,the abdominal CT showed the enlargement of pancreas with the probability of pancreatic divisum.Then he was diagnosed as pancreatitis and the symptomatic treatment was applied but the effect was not comfortable.So he went to the No.1 subsidiary hospital of ZhengZhou University. The abdominal CT showed there were some enlarged lymph nodes in the abdominal cavity and the duodenal wall had became thickened.The pathological examination report of the duodenal wall showed he was diagnosed T lymphoma.For accurate diagnosis,his family sent the pathologi