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南昌病史翻译-南昌医学翻译公司

 原文:

病史摘要:因“咳嗽2月余,发现肺部占位3天”。于2013.5.9入院,胸部CT(ZS13108461)示:左肺上叶MT伴肺门及纵膈淋巴结转移、两肺转移机会大,左肺上叶局限阻塞性肺不张,左侧胸腔积液;进一步行支气管镜活检,病理示:(左主支气管壁及固有上叶粘膜)镜下为支气管壁组织,支气管壁固有膜内可见异型细胞,倾向低分化癌,诊断为肺恶性肿瘤。近日诉乏力加重,右手握力下降,精细动作调节欠佳;无头痛、恶心、呕吐等症状;查体:神清、气平,心肺听诊无殊,双下肢无水肿,左、右侧肌力IV级,双下肢肌力V级,肌张力正常。入院后头颅平扫+增强+DWI示:脑内多发转移MT;脑内见多发结节状稍长T1、稍长T2信号影,部分信号混杂,周围见不规则水肿区,左侧侧脑室受压变形,中线结构居中,脑沟裂尚可。

译文:
Case history: 

The patient was admitted to our hospital due to cough for more than 2 months combined with a space occupying lesion in lung for three days on May 09, 2013. Chest CT scan (No. ZS13108461) indicated malignant tumors in superior lobe of left lung, metastasis in mediastinal lymph node and pulmonary hilums, as well as highly suspected metastasis in both lungs. Localized obstructive atelectasis was found in superior lobe of left lung. Hydrops were observed in left pleura. Further bronchoscopic biopsy was performed, and pathology indicated bronchial wall tissue was examined under the microscope (the wall of left principal bronchus and lamina propria of superior lobe). Poorly differentiated, heterotypic cells were seen in lamina propria of bronchial wall. On this basis, pulmonary malignant tumor was diagnosed. Recently, the patient complained of aggravated acratia and a decline of right hand strength. Further, regulation of fine movements was unsatisfactory. No headache, nausea or vomiting was reported by the patient. Physical examination demonstrated the patient showed satisfactory consciousness and mental status. No abnormality was identified in the heart and lungs per auscultation. No edema was found in both lower extremities. Bilateral muscle strength was at grade IV, and muscle strength of both lower extremities was at grade V. Muscular tension was normal. After admission, multiple metastatic malignant tumors were found in the brain using non-contrast MRI scan, contrast enhanced MRI scan and diffusion weighted imaging (DWI). Multiple nodular, slightly long T1 and T2 signal shadows were seen in the brain. Part of signals was complex. Irregular edema was found in the adjacent areas. Left lateral ventricles were compressed. Median line of brain was centered. Brain sulcus and fissure were satisfactory. 


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