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病历翻译-胰腺癌(出院诊断说明书翻译)

患者因上腹饱胀2个月,发现胰腺癌3天入院。入院查体:腹部平软,来见I胃肠型及蠕动波,未见腹壁静脉曲张,腹软,全腹无压痛、反跪痛及肌紧张,肝脾肋下来触及,来触及包块,移动性浊音阴性,肠鸣青可闻及4次/分。入院后行PET-CT示: 1.胰腺体尾部病灶,考虑恶性(胰腺癌可能性大),2.腹膜后及腹腔内多发肿大淋巴结,考虑转移;腹膜,大同膜及肠系膜增厚,局部结节,考虑转移。直肠精囊间肿物,考虑转移; 肝脏表面与龋肌见肿物,考虑转移。牌胜被膜下低密度灶,考虑转移。3.腹盆腔内肠管管壁广泛增厚,待除外转移。4.右肾囊肿。双肾小结石。肝内钙化灶。5.腹水;盒腔积液。予行腹腔穿刺置管排放积液,腹水细胞学病理示:腺癌。根据病史查体及辅助检查明确临床诊断:胰腺癌(T2NIM1)IV期,腹腔内、腹膜后多发淋巴结转移,腹膜多发转移,脾转移,右肾囊钟,双肾小结石,2型糖尿病。予氟尿嘧啶腹腔灌注化疗治疗,现患者轻度腹胀,双肩部酸胀不适,查体同前,患者及家属要求行全身性化疗治行,告知化疗相关费用,注意事项及可能出现的不良反应,患者及家属要求行门诊化疗,予办理出院。

discharge abstract:
The patient admitted to the hospital for pancreatic cancer 3 days due to superior belly glutted 2 months. Physical examination after admission: flat and soft abdomen, without gastrointestinal type and peristaltic wave observed, no abdominal wall varicosis, soft abdomen, without tenderness in the whole abdomen, rebound tenderness and muscular tension, liver, spleen and sub-costal as well as mass un-involved, negative shifting dullness, audible bowel sounds 4 times/min. After admission, PET-CT was conducted as follows: 1. Body and tail focus of the pancreas, considered to be malignant (high possibility of pancreatic cancer). 2. Retroperitoneal and intraperitoneal multiple enlarged lymph nodes, considered metastasis; Peritoneum, omentum majus and mesentery were thickened, local nodules, metastasis considered. Tumor between rectum and seminal vesicle, metastasis considered; Mass was visible at the liver surface and diaphragm, metastasis considered. Spleen subcapsular low density focus, metastasis considered. 3. The wall of the intestinal canal in the abdomen and pelvis is widely thickened, metastasis to be excluded. 4. Right kidney cyst. Bilateral kidney microlithiasis. Intrahepatic calcification. 5. Ascites; Pelvic effusion. Abdominal paracentesis catheterization was conducted to drain the effusion. Cytology of ascites pathology showed adenocarcinoma. Based on the medical history, physical examination and auxiliary examination, determine the clinical diagnosis: pancreatic cancer (T2N1M1) stage IV, intraperitoneal and retroperitoneal multi-lymph node metastases, peritoneum multiple metastasis, splenic metastasis, right kidney cyst, bilateral renal microlithiasis, type 2 diabetes. Fluorouracil peritoneal perfusion chemotherapy was given, currently, the patient had mild abdominal distension and discomfort of soreness-distension for both shoulders, physical examination as mentioned above, the patient and his family required systemic chemotherapy treatment, and were informed of the expenses relevant with chemotherapy, points for attention and possible adverse reactions, the patient and the family required outpatient chemotherapy, approved discharge.

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