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肺部CT檢查報告中英翻譯模板

發(fā)表時間:2021/08/10 00:00:00  瀏覽次數(shù):1918  
字體大小: 【小】 【中】 【大】

肺部CT作為肺癌診斷的一種常規(guī)手段,是國外就醫(yī)必須的材料之一。與MRI,PET/CT等材料一起涵蓋在影像學分類中。在向國外醫(yī)院提供該部分材料時,準確地做法是將帶文字的材料進行翻譯,然后將膠片進行拍照(白天用高清相機,對著白墻拍照)。以pdf格式或dicom格式發(fā)給國外醫(yī)生。針對文字翻譯部分,現(xiàn)提供幾個樣例,供大家參考。


原文:
骶前區(qū)可見多發(fā)淋巴結(jié),大者短徑約1.0 cm (圖2-60〕,余腹盆腔及腹膜后、雙側(cè)腹股溝區(qū)未見明確腫大淋巴結(jié)。
肝臟可見多發(fā)結(jié)節(jié)及腫物, 大者約4.6 X 3.9 cm (圖2-6〕,邊界欠清。
雙腎多發(fā)低密度灶,大者約1.3 cm,界淸。
膽囊、胰腺、脾臟、副脾結(jié)節(jié)、雙側(cè)腎上腺、膀胱、前列腺、雙側(cè)精囊腺未見明確異常。
未見腹水征象。
“直腸癌”參閱2016-3-15胸部CT圖像:
1、圖2-25所示右肺小結(jié)節(jié)較前略有縮小,約0.3 cm。圖2-39左下肺小類結(jié)節(jié)大致同前。右腫中葉斑片影同前相仿。
2、余雙肺未見明確新病灶。
3、縱隔淋巴結(jié)、肺門淋巴結(jié)未見明確腫大淋巴結(jié)。
4、雙側(cè)胸腔、心包未見積液。
5、掃描范圍內(nèi)肝內(nèi)可見多發(fā)結(jié)節(jié)及腫物較前縮小,邊界模糊,大者約3.4*2.5 cm〔圖57〉,請結(jié)合腹部檢查。

譯文:
Scanning technique: contrast enhanced scan, slice thickness, 5 mm. 
Findings:
For the imaging findings of colorectal carcinoma, please refer to the chest CT performed on Mar. 15, 2016. 
1. The small nodules in the right lung was decreased in size (about 0.3 cm smaller than the previous one) compared with the previous image. The small nodule in the left lower lung was similar as before. The plaque-like shadows in the middle lobe of right lung was similar as before. 
2. No new lesions were noticed in the rest parts.
3. No definite swelling was noticed in the mediastinal lymph node and the hilar lymph node. 
4. No hydrops was noticed in the bilateral thoracic cavity and the pericardium. 
5. Multiple lymph nodes and tumor mass in the liver were decreased in size with vague margins. The larger showed a size of 3.4×2.5 cm. The refer to the abdominal examination. 
Multiple lymph nodes were noticed in the presacral region with the larger one showed a short diameter of 1.0 cm, which was similar as before. No definite swelling was noticed in the lymph nodes localized in the abdomen and pelvic cavity, retroperitoneal lymph nodes, and bilateral inguinal lymph nodes, respectively.
Multiple nodules and tumor mass were noticed in the liver, with the larger one showed a size of 4.6× 3.9 cm. The margins were vague. 
Multiple low intensity lesions were noticed in both kidneys with the larger size showed a size of 1.3 cm. The margins were clear. 
No definite abnormalities were noticed in the gallbladder, pancreas, spleen, accessory spleen, adrenal gland, bladder, prostate, and bilateral seminal vesicle. 
No signs of ascites were noticed. 

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