5份中英文病例讨论.pdf

英文病例2

英语病例书写

病历讨论1

患者，女，45岁，因反复右上腹隐痛不适5年余而入院。

患者5年前起，渐感右上腹经常性隐痛不适，疼痛呈间歇性隐痛，有时为绞痛，并向右

肩放射，发作时有阵发性加剧，伴轻度恶心，无呕吐，疼痛有时可自行缓解，有时需来院

“输液治疗”才能缓解，无肛门停止排气、排便以及腹胀。疼痛多在进食油腻食物后诱发，

发作时无明显发烧以及皮肤巩膜黄染。患者反复治疗多次，症状仍反复出现，来院门诊而收

入院。自起病以来，患者一般情况可，除油腻食物外，余基本能正常进食，大小便正常。

查体：T37.2℃，P72次/分，R15次/分，Bp120/70mmHg

神清、合作，自动体位,无特殊病容，皮肤、巩膜无黄染，头、颈、胸部无特殊阳性体征，

腹部平、软，右上腹有轻度深压痛，无明显反跳痛，未触及包块，肝脾肋下未及，Murphy’s

sign阳性，无移动性浊音，肠鸣音正常，未闻及气过水声。r

辅助检查：

1.Hb112g/L,WBC8.0*10e9,N0.70,L0.25

2.腹透：未见膈下游离气体，未见扩大的肠管及液气平面。

Patient,female,45yearsold,wasadmittedbecauseofrepeatedvaguepain

locatedintherightupperquadrantfor5years.

Fiveyearsago,thepatientgraduallyfeltrepeatedvaguepainlocatedinright

upperquadrant.Thepainwasintermittent，colicsometimesandradiatedtoright

shoulder.Thepaincouldbegoingworseparoxysmallywithslightnauseaandwithout

vomiting.Thepainsometimescouldberelievedbyitself,sometimesrelievedby

transfusemanagement.Noabdominaldistention.Nogasanddefecationstop.The

painwasmostlyinducedbygreasyfoodwithoutobviousfeverandstainedyellowof

skinandsclera.Thepatientreceivedrelapsetreatments,sufferedfromrelapsepain

andwasadmittedfromtheout-patientclinic.Sinceonset,hisgeneralstatewasgood.

Foodscouldbetakenexceptgreasyfood.Defecationandurinationwerenormal.

PhysicalExamination：T.37.2C,P.72/min,R.15/min,BP.120/70mmHg

Thepatient’sconsciousnesswasclear,andwasinactiveposition，theskinand

sclerawerenotstainedyellow.Therewasnospecialpositivesignonhead,neckand

chest.Abdomenwasflatandsoft.Slighttendernesscouldbefeltintherightupper

abdomen,reboundtendernessnegative.Masswasnottouched.Liverandspleenwere

untouched.Shiftingdullnessnegative.Bowelsoundwas