| seg |
| 上海中醫(yī)藥大學(xué)附屬龍華醫(yī)院出院小結(jié) |
| Discharge Summary of Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine |
| 姓名：*** 科別：腫瘤七科 病區(qū)：二十六病區(qū) 床號(hào)：14住院號(hào)：0823817 |
| Name: *** Department: Oncology the 7th Department Ward No.: 26 Bed No.: 14 Hospital No.: 0823817 |
| 更診時(shí)間及后續(xù)治療：門診隨訪，定期復(fù)查，聯(lián)系電話64385700-8163（醫(yī)）,8168 （護(hù)）；我科來(lái)電顯示：02133324000 |
| Time in service of hospital and follow-up treatment: outpatient follow-up, and regular review, Contact Number 64385700-8163 (medical), 8168 (nursing); Tel. Number of our department: 02133324000 |
| 相關(guān)醫(yī)生門診安排： |
| Outpatient Arrangements of Related MD : |
| 特需門診：楊金祖 周三全天（總院） |
| VIP Clinic: Jinzu Yang all day on Wednesday (General Hospital) |
| 專家門診：楊金祖 周二下午（總院）；楊金祖 周四上午（總院）：武清 周一下午，周三上午（總院） |
| Specialist clinic: Yang Jinzu Tuesday afternoon (General Hospital); Yang Jinzu Thursday morning (General Hospital): Wuqing Monday afternoon, Wednesday morning (General Hospital) |
| 普通門診：周三下午 |
| General clinic: Wednesday afternoon |
| 病房抄方時(shí)間：周三下午 |
| Time for copying prescriptions in the ward: Wednesday afternoon |
| 轉(zhuǎn)外院治療： |
| Transfer to another hospital for treatment: |
| 后續(xù)醫(yī)療服務(wù)機(jī)構(gòu)名稱及地址： |
| Name and address of follow-up medical service institution: |
| 中醫(yī)調(diào)護(hù)：避風(fēng)寒.調(diào)飲食,暢情志，慎起居 |
| Traditional Chinese medicine care: avoid wind and cold, adjust diet, smooth emotions, and be cautious in daily life |
| 緊急就醫(yī)的情況：如出現(xiàn)發(fā)熱、惡心嘔吐等不適癥狀，諳立即至急診就診。 |
| Emergency medical treatment: If symptoms such as fever, nausea, or vomiting occurs, go to the emergency department immediately. |
| 治療結(jié)果 好轉(zhuǎn) |
| Treatment results: Improved |
| 主治醫(yī)師: |
| Attending Physician: |
| 日期：2023-03-10 |
| Date: Mar. 10, 2023 |
| 住院醫(yī)師: 日期：2023年03月10日 |
| Residency Physician: Date: Mar. 10, 2023 |
| 爨掃描全能王創(chuàng)建 |
|
| 上海中醫(yī)藥大學(xué)附屬龍華醫(yī)院出院小結(jié) |
| Discharge Summary of Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine |
| 姓名：*** 科別：腫瘤七科 病區(qū)：二十六病區(qū) 床號(hào)：14住院號(hào)：0823817 |
| Name: *** Department: Oncology the 7th Department Ward No.:26 Bed No.: 14 Hospital No.: 0823817 |
| umol/L ,尿素（干式）5. 01 mmol/L ,尿酸（干式）307 umol/L，鉀（干式）4. 1 mmol/L，鈉（干式） 132.9 mmol/L . |
| umol/L, urea (dry) 5.01 mmol/L, uric acid (dry) 307 umol/L, potassium (dry) 4.1 mmol/L, sodium (dry) 132.9 mmol/L. |
| 特殊檢查結(jié)果及主要會(huì)診（注明日期與檢查號(hào)） 無(wú) |
| Special inspection results and major consultations (specify date and inspection number) : None |
| 病程與治療結(jié)果（注明手術(shù)日期、手術(shù)名稱、輸血以及搶救情況） |
| Disease course and treatment results (indicate operation date, operation name, blood transfusion and rescue status) |
| 患者四月前因反復(fù)腹部隱痛不適，遂于2022. |
| The patient had abdominal pain and discomfort repeatly in four months ago, and then |
| 9月至復(fù)旦大學(xué)附屬腫瘤醫(yī)院就診，2022.09. 15腫瘤標(biāo)志物:CA199:7459U/ml, CA125:79. 2U/ml, CA153:4. 94U/ml, CA724:2. 32U/ml, CA50: >500IU/ml, CA242: > 200U/ml. |
| visited Fudan University Shanghai Cancer Center on Sept. 15 2022. Tumor markers: CA199: 7459U/ml, CA125: 79. 2U/ml, CA153: 4. 94U/ml, CA724: 2. 32U/ml, CA50: > 500IU/ml, CA242: > 200U/ml. |
| AFP:2.43ng/ml, CEA: 165ng/ml. |
| AFP: 2.43ng/ml, CEA: 165ng/ml. |
| 2022-09-15 查【PET-CT】報(bào)告示：1.胰體部軟組織腫塊影，F(xiàn)DG 代謝增高，考慮為MT可能大，侵犯左側(cè)腎上腺及胃后壁。 |
| 2022-09-15 [PET-CT] report showed: 1. Soft tissue mass shadows in the body of the pancreas, increased FDG metabolism, it is considered that the MT possibiity is high, invading the left adrenal gland and the back wall of the stomach. |
| 2022. 09. 20行超聲引導(dǎo)下胰體尾腫瘤穿刺,2022- 09-21穿刺細(xì)胞病理診斷示：見(jiàn)腺癌細(xì)胞,遂于腫瘤醫(yī)院2022-09-22至2023-01-12行AG方案化療（紫杉醇 170mg dl+吉西他濱1.4g dl） 4程.2023-01-31于復(fù)旦大學(xué)附屬腫瘤醫(yī)院［PET-CT］示：1.胰腺癌化療后，胰體MT較前相仿，仍FDG代謝異常增高，侵犯左側(cè)腎上腺及胃后壁；新見(jiàn)胸骨、右側(cè)股骨上段轉(zhuǎn)移；新見(jiàn)兩側(cè)鎖骨上淋巴結(jié)轉(zhuǎn)移可能。 |
| 2022.09.20 Ultrasound-guided pancreatic tail tumor puncture, 2022-09-21 Puncture cytological diagnosis showed: adenocarcinoma cells were seen, and AG chemotherapy was performed in the Cancer Hospital from Sept. 22, 2022 to Jan. 12, 2023 (Paclitaxel 170mg dl + Gemcitabine 1.4g dl) 4 courses. On Jan. 31,2023 at Fudan University Cancer Hospital, the [PET-CT] showed: 1. After pancreatic cancer chemotherapy, pancreatic MT was similar as before, FDG metabolism was still abnormally increased, Invading the left adrenal gland and the posterior gastric wall; new metastasis to the sternum and right upper femur; new possible metastasis to supraclavicular lymph nodes on both sides. |
| 2023-02-09、2023-03-02我科行AG方案C5治療：AG化療方案（白蛋白紫杉醇200mg +吉西他濱L 4g ivgtt dl）,此次入院后完善相關(guān)檢查，患者病理診斷明確，ECOG評(píng)分合格，心 電圖及生化檢查合格，排除相關(guān)禁忌，經(jīng)主任同意，2023-03-09行腹腔干+腸系膜上動(dòng)脈化療術(shù)（白蛋白紫杉醇100mg+吉西他濱0.4g IA）,并子樞星止嘔，愛(ài)麗安護(hù)胃，美能護(hù)肝。 |
| on Feb. 9, 2023 and Mar. 2, 2023, Our department performed C5 treatment of AG program: AG chemotherapy program (nab-paclitaxel 200mg + gemcitabine L 4g ivgtt dl), relevant examinations were completed after admission, the patient’s pathological diagnosis was clear, and the ECOG score was qualified, the electrocardiogram and biochemical examination were qualified, and the relevant contraindications were excluded. With the consent of the director, celiac trunk + superior mesenteric artery chemotherapy (nab-paclitaxel 100mg + gemcitabine 0.4g IA) was performed on March 09, 2023, with Granisetron Hydrochloride Tablets for relieving vomiting, Ilaprazole Enteric-coated Tablets for protecting the stomach, and SNMC for protecting liver. |
| 余治療于門冬胰島素30早12u-晚 11u皮下。 |
| Insulin aspart 30 was given with 12u in the morning and 11u in the afternoon as treatment by subcutaneous injection |
| 查患者舌淡紅，苔薄白，脈細(xì)，證屬“胰癌脾氣虛證”，子通關(guān)藤、康艾清熱解毒抗腫痛，正得康膠囊扶正抗腫瘤，配合耳針益氣扶正。 |
| The patient had a pale red tongue, thin white fur, and thready pulse. The syndrome belongs to “pancreatic cancer with spleen deficiency syndrome”. Medicines of Marsdeniae Tenacissimae Caulis，Kang‘a(chǎn)i Zhusheye，Zhengdekang capsule and acupunctur threapy are given for cancer treatment. |
| 經(jīng)治療，患者癥情緩解，經(jīng)上級(jí)醫(yī)師同意，準(zhǔn)予出院。 |
| After that, the patient’s symptoms were relieved, and the patient was allowed to leave the hospital with the consent of the superior physician. |
| 合并癥 |
| Complications |
| 無(wú) |
| None |
| 出院時(shí)情況（癥狀與體征） 出院時(shí)患者左側(cè)腹部脹痛較前緩解，無(wú)明顯不適，乏力較前緩解，胃納可，二便調(diào)，夜寐一般“查體:神清，精神可，全身皮膚粘膜未見(jiàn)黃染，無(wú)水腫及皮下出血點(diǎn)及結(jié)節(jié)，淺表淋巴結(jié)未及腫大，鞏膜正常，口唇無(wú)紫紺。 |
| Health status at discharge (symptoms and signs) When discharged from the hospital, the left abdomen pain of the patient was relieved without obvious discomfort, fatigue was relieved, appetite was acceptable, night soil and urine were normal, and night sleep was normal. No jaundice was found on the skin or mucous membranes of the whole body, no edema, no subcutaneous bleeding points or nodules, superficial lymph nodes were not enlarged, the sclera was normal, and the lips were not cyanotic. |
| 雙肺呼吸音清，未聞及干濕啰音。 |
| Breath sounds in both lungs were clear. Dry or wet rales were not heard. |
| 心率76次/分，律齊，各瓣膜區(qū)未聞及病理性雜音腹平軟。 |
| The heart rate was 76 beats/min and regular, No pathological murmurs were heard in each valve area, and the abdomen was flat and soft. |
| 腹壁睜脈無(wú)曲張，無(wú)壓痛及反跳痛，肝脾肋下未觸及，未及包塊，肝區(qū)叩痛（-）。 |
| No varicose veins in the abdominal wall, no tenderness or rebound pain, no palpation of the liver and spleen under the ribs, no mass, There is pain on percussion in the liver area (-). |
| 無(wú)移動(dòng)性濁音，無(wú)腎區(qū)叩擊痛，腸鳴音4次/分，無(wú)雙下肢水腫，四肢肌力肌張力正常，生理反射正常，病理反射未引出。 |
| No shifting dullness, no percussion pain in the kidney area, bowel sounds 4 times/min, no lower limb edema, normal muscle strength and muscle tone in the four limbs, normal physiological reflexes, and no pathological reflexes. |
| 出院后用藥及建議 |
| Medication and advice after discharge |
| .出院帶藥：得康膠囊*1盒 每日三次，每次4粒 口服 |
| Discharge medicine: Dekang Capsule*1 box, three times a day, 4 capsules each time orally |
| .自備藥:門冬胰島索30 早12u-晚11u皮下。 |
| Self-prepared medicine: insulin aspart 30 12u-in the morning 11u at night by subcutaneous injection. |
| .藥物潛在副作用：詳見(jiàn)說(shuō)明書 |
| . Potential side effects of the medicine: see the instructions for details |
| .后續(xù)醫(yī)療服務(wù)的安排：門診隨訪，定期及查，如有不適及時(shí)就診. |
| .Arrangement of follow-up medical services: outpatient follow-up, regular check-ups, and timely visit hospital if there is any discomfort. |
| 本院門診隨訪 |
| Outpatient follow-up in our hospital |
| m掃描全能王創(chuàng)建 |
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| / |
| / |
| 上海中醫(yī)藥大學(xué)附屬龍華醫(yī)院出院小結(jié) |
| Discharge Summary of Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine |
| 姓名：*** 科別：腫瘤七科病區(qū)：二十六病區(qū)床號(hào)：14 住院號(hào)：0823817 |
| Name: *** Department: Tumor the 7th Department Ward No.: 26 Bed No.: 14 Hospital No.: 0823817 |
| 姓名：*** 性別：女年齡：50歲住院號(hào)：0823817 |
| Name: *** Gender: Female Age: 50 Admission No.: 0823817 |
| 入院日期 2023-03-07 09:01出院日期 2023-03-10 15:00門診診斷 |
| Admission Date Mar. 7, 2023 09:01 Discharge Date Mar. 10, 2023 15:00 Outpatient Diagnosis |
| 中醫(yī)診斷：胰癌、脾氣虛證 |
| Traditional Chinese Medical Diagnosis: Pancreatic Cancer, Spleen Deficiency Syndrome |
| 西醫(yī)診斷:胰腺惡性腫痛C-T4N1M1 （左側(cè)腎上腺、胃后壁、骨）2型循尿病 |
| Western medicine diagnosis: pancreatic malignant swelling and pain C-T4N1M1 (left adrenal gland, back wall of stomach, bone) type II diabetes |
| 入院診斷 |
| Admission diagnosis |
| 中醫(yī)診斷：胰癌、脾氣虛證 |
| Traditional Chinese Medical Diagnosis: Pancreatic Cancer, Spleen Deficiency Syndrome |
| 西醫(yī)診斷：腹腺惡性腫瘤C-T4N1M1 （左側(cè)腎上腺、胃后壁、骨）2型糖尿病 |
| Western medicine diagnosis: abdominal gland malignant tumor C-T4N1M1 (left adrenal gland, back wall of stomach, bone) type II diabetes |
| 出院診斷 |
| Discharge diagnosis |
| 中醫(yī)診斷：胰癌、脾氣虛證 |
| Traditional Chinese Medical Diagnosis: Pancreatic Cancer, Spleen Deficiency Syndrome |
| 西醫(yī)診斷：胰腺惡性腫瘤C-T4N1M1 （左側(cè)腎上腺、胃后壁、骨）2型糖尿病 |
| Western medicine diagnosis: pancreatic malignant tumor C-T4N1M1 (left adrenal gland, back wall of stomach, bone) type 2 diabetes mellitus |
| 入院時(shí)主要癥狀及體征 |
| Main symptoms and signs on admission |
| 入院時(shí)患者左側(cè)腹部脹痛，按之痛甚，進(jìn)食后緩解，乏力，胃納可，二便調(diào)，夜寐一股。 |
| When admitted to the hospital, the patient had distending pain in the left abdomen, which was very painful when pressed, and was relieved after having food. fatigue, normal appetite, bowels and urine open, and normal night sleep. |
| PE:神清，精神可，全身皮膚粘膜未見(jiàn)黃染，無(wú)水腫及皮下出血點(diǎn)及結(jié)節(jié)，淺表淋巴結(jié)未及腫大，鞏膜正常，口唇無(wú)紫紺。 |
| PE: good consciousness, energetic, no jaundice in skin mucosa of the whole body, no edema, subcutaneous bleeding points or nodules, no superficial lymph node enlargement, normal sclera, and no cyanosis of lips. |
| 雙肺呼吸音清，未聞及干濕啰音。 |
| Breath sounds in both lungs were clear. Dry or wet rales were not heard. |
| 心率80次/分，律齊，各瓣膜區(qū)未聞及病理性雜音腹平軟。 |
| The heart rate was 80 beats/min and regular, no pathological murmurs were heard in each valve area, and the abdomen was flat and soft. |
| 腹壁靜脈無(wú)曲張，無(wú) 壓痛及反跳痛，肝脾肋下未觸及,未及包塊，肝區(qū)叩痛（-）.無(wú)移動(dòng)性濁音，無(wú)腎區(qū)叩擊痛，腸鳴音4次/分，無(wú)雙下肢水腫，四肢肌力肌張力正常，生理反射正常，病理反射未引出。 |
| No varicose veins in the abdominal wall, no tenderness or rebound pain, no palpation of the liver and spleen under the ribs, no mass, percussion pain in the liver area (-). No shifting dullness, no percussion pain in the kidney area, bowel sounds 4 times/min. No lower limbs edema, normal muscle strength and muscle tone of four limbs, normal physiological reflex, no pathological reflex elicited. |
| 主要檢查結(jié)果 |
| Main inspection results |
| 2023-03-08血常規(guī)：白細(xì)胞計(jì)數(shù)3. |
| 2023-03-08 Blood routine: white blood cell count |
| 40 x109/L ,中性粒細(xì)胞百分比66. |
| 3.40 x10^9/L , neutrophil percentage 66. |
| 1 % ,紅細(xì)胞計(jì)數(shù)4.14 xlO12/L ,血紅蛋白量111 g/L ,血小板計(jì)數(shù)224 x109/L ,超敏C反應(yīng)蛋白<0. 50 mg/L ,血清淀粉樣蛋白A 35. 04 mg/L。 |
| 1%, red blood cell count 4.14 x10^12/L, hemoglobin 111 g/L, platelet count 224 x10^9/L, hypersensitive C-reactive protein <0. 50 mg/L, serum amyloid A 35. 04 mg/L. |
| 生化：白蛋白（干式）38.9 g/L,丙氨酸氨基轉(zhuǎn)移酣（干式）17 U/L ,天冬氨酸氨基轉(zhuǎn)移酶（干式）21 U/L . γ-谷氨酰轉(zhuǎn)肽酶（干式）19 U/L ,肌酐（干式）38.3 umol/L ,尿素（干式） 4. 38 mmol/L ， 尿酸（干式）218 umol/L .鉀（干式）5. 0 mmol/L，鈉（干式）137. 1 mmol/L。 |
| Biochemical: Albumin (dry) 38.9 G/L, Alanine Transaminotransferase (dry) 17 U/L, Aspartate Aminotransferase (dry) 21 U/L. Γ-glutamyl Transfer Peptidase (dry) 19 U/L, Creatinine (dry) 38.3 Umol/L, Urea (dry) 4.38 Mmol/L, Uric Acid (dry) 218 Umol/L, Potassium (dry) 5. 0 Mmol/L, Sodium (dry ) 137.1 Mmol/L. |
| 凝血： 凝血酶原時(shí)間11.8秒，國(guó)際標(biāo)準(zhǔn)化比值（INR） 1.04，活化部分凝血活酶時(shí)間25.8秒，D二聚體1.24,凝血因子VIII174 % t . |
| Coagulation: Prothrombin Time 11.8 Seconds, International Normalized Ratio (INR) 1.04, Activated Partial Thromboplastin Time 25.8 Seconds, D Dimer 1.24, Coagulation Factor VIII 174 % |
| 2023-03-10門急診檢驗(yàn)報(bào)告：白細(xì)胞計(jì)數(shù)5. |
| 2023-03-10 Outpatient emergency test report: white blood cell count 5. |
| 28 xI09/L,中性粒細(xì)胞絕對(duì)值 3.77 xlO9/L .紅細(xì)胞計(jì)數(shù)4. |
| 28 xI0^9/L, Absolute Value Of Neutrophils 3.77 XlO^9/L. Red Blood Cell Count 4. |
| 10 x10l2/L ,血紅蛋白量110 g/L I ,血小板計(jì)數(shù)195 x109/L . 超敏C反應(yīng)蛋白<0. 50 mg/L 。 |
| 10 x10^l2/L, Hemoglobin 110 g/L I, Platelet Count 195 X10^9/L. Hypersensitive C-reactive Protein <0. 50 mg/L. |
| 門急診檢驗(yàn)報(bào)告：白蛋白（干式）38.3 g/L,丙氨酸氨基轉(zhuǎn)移酶（干式）15 U/L ,天冬氨酸氨基轉(zhuǎn)移酶（干式）18 U/L , Y-谷氨酰轉(zhuǎn)肽酶（干式）18 U/L ,肌酐（干式）43.6 |
| Outpatient and emergency test report: Albumin (dry ) 38.3 G/L, Alanine Aminotransferase (dry) 15 U/L, Aspartate Aminotransferase (dry) 18 U/L, Y-glucose Amyltranspeptidase (dry) 18 U/L, Creatinine (dry ) 43.6 |
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| m掃描全能王創(chuàng)建 |
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| 復(fù)旦大學(xué)附屬腫瘤醫(yī)院 核醫(yī)學(xué)科 |
| Cancer Hospital Affiliated to Fudan University Department of Nuclear Medicine |
| PET |
| PET |
| 檢查報(bào)告單 |
| Physical Examination Report |
| 影像號(hào)：11407881 |
| Image number: 11407881 |
| 姓名：*** 性別1女 |
| Name: *** Gender: Female |
| 檢查方式核素 |
| Examination method: nuclide |
| 申請(qǐng)科室 |
| Department Application |
| 臨床論斷: |
| Clinical conclusion: |
| PET/CT 斷層 |
| PET/CT tomography |
| 藥物： FDG胰腺外科 |
| Medicine: FDG Pancreatic Surgery |
| 胰腺癌化療后 |
| Pancreatic Cancer After Chemotherapy |
| 年齡50 歲 |
| Age: 50 |
| 檢查部位：全身 |
| Inspection Area: whole body |
| 劑量 6.048mCi |
| Dosage 6.048mCi |
| 檢查日期,2023-01-31 |
| Inspection date, Jan. 31, 2023 |
| 門診號(hào) 310104197210274823 |
| Clinic No. 310104197210274823 |
| 床號(hào) |
| Bed No. |
| 血糖：6. 2mmol/L |
| Blood sugar: 6. 2mmol/L |
| 檢查項(xiàng)目：腫瘤全身斷層顯像 |
| Inspection items: Tumor whole body tomography |
| 給藥方式：靜脈注射 注射部位:右手腕 |
| Administration method: intravenous injection Injection part: right wrist |
| 檢查排號(hào)：25 |
| Queue number for examination: 25 |
| — |
| — |
| 體檢發(fā)現(xiàn)多項(xiàng)腫瘤指標(biāo)升高就診:2022. 9 本院PET/CT：肢體部軟組織腫塊影，F(xiàn)DG代謝增高,考再為MT可能大.侵犯左側(cè)腎上腺及胃后壁.2022.9本院EUS：質(zhì)腺體部占位,活檢病理：腺癌.后化療4程。 |
| A number of tumor indicators were found to be elevated in the physical examination and visit the hospital: In Sept., 2022. PET/CT in our hospital: soft tissue mass shadow in the limbs, FDG metabolism increased, high MT possibility was considered. Invasion of the left adrenal gland and the back wall of the stomach. Sept. 2022 EUS in our hospital: Gland space occupying, biopsy pathology: adenocarcinoma. Chemotherapy with 4 courses. |
| 2023. 1 |
| Jan. 2023 |
| 本院 |
| This hospital |
| CA19-9：6351. |
| CA19-9:6351. |
| OOU/mI, CA19-9_H:6351. 00U/mI, CA125:52. 80U/ml,CA50:>500. 00lU/mL, CA242：>200. 00U/m |
| OOU/mI, CA19-9_H:6351. 00U/mI, CA125:52. 80U/ml, CA50:>500. 00lU/mL, CA242:>200. 00U/m |
| 檢杳所見(jiàn)： |
| Examination Result: |
| 禁食狀態(tài)下.靜脈注射F-18-FDG,體息約60分鐘，行PET/CT顯像，圖像顯示清晰,與前片對(duì)比（2022. 09.15）. |
| In the fasting state. F-18-FDG was injected intravenously, and rested for about 60 minutes. PET/CT imaging was performed, and the image was clearly displayed, comparing with the previous film (Sept. 15, 2022). |
| 胰腺癌化療后.肢體部軟組織腫塊影大小基本同前，邊界欠清，侵犯左側(cè)腎上腺及胃后壁，放射性攝取增高基本同前，SUVmax=4.1 （前片4.4）： |
| After chemotherapy for pancreatic cancer, the size of the soft tissue mass in the extremities is basically the same as before, with unclear borders, invading the left adrenal gland and the back wall of the stomach, and the increase in radioactive uptake is basically the same as before, SUVmax=4.1 (4.4 in the previous film): |
| 肝臟形態(tài)、大小正常，密度均勻， 放射性分布未見(jiàn)明顯異常.肝內(nèi)外膽管皆未見(jiàn)明顯獷張； |
| The shape and size of the liver were normal, the density was uniform, and there was no obvious abnormality in the distribution of radioactivity. There was no obvious swelling of the bile ducts inside and outside the liver; |
| 膽囊壁未見(jiàn)明顯增厚，未見(jiàn)放射性攝取異常增高灶： |
| There was no obvious thickening of the gallbladder wall, and no abnormally increased radioactive uptake foci: |
| 脾臟大小正常，放射性分布均勻； |
| The size of the spleen is normal and the distribution of radioactivity is uniform; |
| 腸道各段見(jiàn)少量生理性放射性攝取： |
| A small amount of physiological radioactive uptake is seen in various segments of the intestinal tract: |
| 右側(cè)腎上腺形態(tài)未見(jiàn)明顯異常，未見(jiàn)明顯放射性異常攝取； |
| There was no obvious abnormality in the shape of the right adrenal gland, and no obvious abnormal uptake of radioactivity; |
| 雙腎實(shí)質(zhì)未見(jiàn)異常密度影及放射性異常增高灶，腎孟、腎盞未見(jiàn)明顯擴(kuò)張； |
| There were no abnormal density shadows and abnormally increased radioactive foci in the renal parenchyma, and no obvious expansion of the renal calices and pelvis; |
| 膀胱充盈欠佳； |
| Poorly filling bladder; |
| 子客體積增大，左后緣凸起略低密度灶同前，子宮另見(jiàn)數(shù)個(gè)結(jié)節(jié)樣略高密度影，均未見(jiàn)放射性攝取增高； |
| The volume of the uterus increases, the left posterior margin bulges slightly low density foci are the same as before, and several nodular with slightly high density shadows are seen in the uterus, all of which have no increased radiation uptake; |
| 雙側(cè)附件區(qū)未見(jiàn)明顯放射性異常攝?。?/td> |
| No obvious abnormal radioactive uptake in the bilateral appendages: |
| 腹膜后、兩側(cè)髂血管旁及腹股溝未見(jiàn)明顯腫大淋巴結(jié)。 |
| No obvious enlarged lymph nodes were found in retroperitoneum, beside bilateral iliac vessels or groin. |
| 兩肺及理增粗，散在微小結(jié)節(jié)，均未見(jiàn)放射性攝取增高：縱隔及兩側(cè)肺門淋巴結(jié)未見(jiàn)明顯腫大及放射性異常攝取：食管管壁未見(jiàn)明顯增厚及放射性異常增高灶。 |
| The two lungs were thickened, with scattered tiny nodules, and no increased radioactive uptake was found: no obvious enlargement and abnormal radioactive uptake were found in the mediastinal and bilateral hilar lymph nodes; no obvious thickening of the esophageal wall and abnormally increased radioactive foci were found. |
| 雙側(cè)乳腺未見(jiàn)異常放射性分布：雙側(cè)腋窩及內(nèi)乳未見(jiàn)明顯腫大淋巴結(jié)及放射性攝取異常增高灶。 |
| No abnormal radiation distribution was found in bilateral breasts: no obvious enlarged lymph nodes or abnormally increased radioactive uptake foci were found in bilateral axillaries and inner breasts. |
| 鼻咽頂后壁及兩側(cè)壁未見(jiàn)明顯增厚，咽隱窩及咽旁間隙清晰： |
| The posterior wall of the nasopharyngeal roof and both sides were not thickened, and the pharyngeal recesses and parapharyngeal space were clear: |
| 雙側(cè)上頜竇、篩竇及堞竇 結(jié)構(gòu)未見(jiàn)明顯異常，黏膜未見(jiàn)明顯增厚： |
| There was no obvious abnormality in the structure of the bilateral maxillary sinus, ethmoid sinus, and castellation sinus, and no obvious thickening of the mucosa: |
| 口咽部、兩側(cè)梨狀窩、甲狀腺未見(jiàn)明顯異常密度影及放射性異常增高灶，新見(jiàn)雙側(cè)鎖骨上小淋巴結(jié)，放射性攝取輕度增高，SUVmax=2.7； |
| no obvious abnormal density shadow and abnormally increased radioactive focus at Oropharynx, bilateral pyriform sinuses or thyroid, new bilateral supraclavicular small lymph nodes appears with slightly increased radioactive uptake, SUVmax=2.7; |
| 雙側(cè) 上頸部小淋巴結(jié)，放射性攝取輕度增高，SUVmax=2. 6。 |
| The radioactive uptake was slightly increased in the small lymph nodes of the upper neck bilaterally, SUVmax=2.6. |
| 大腦各葉、雙側(cè)基底節(jié)、丘腦及兩側(cè)小腦放射性分布對(duì)稱，未見(jiàn)明顯放射性攝取異常增高或減低區(qū)；CT平掃顯示腦實(shí)質(zhì)內(nèi)未見(jiàn)異常密度影，中線結(jié)狗居中：腦溝、腦裂、腦池未見(jiàn)明顯增寬、擴(kuò)張。 |
| The radioactivity distribution in each lobe of the brain, bilateral basal ganglia, thalamus and bilateral cerebellum is symmetrical, and there is no obvious abnormal increase or decrease of radioactivity uptake; CT plain scan showed that there was no abnormal density shadow in the brain parenchyma, and the midline structure was in the middle: the sulcus, fissure and cistern were not significantly widened or expanded. |
| 新見(jiàn)胸骨體混合性密度改變，右側(cè)股骨上段成骨性改變，均放射性攝取異常增高， SUVmax=6. 3:所見(jiàn)余處骨骼放射性分布未見(jiàn)明顯異常。 |
| The mixed density change of the sternum body and the osteogenic change of the right upper femur are newly seen, and the radioactive uptake is abnormally high, SUVmax=6 3: There is no obvious abnormality in the radioactive distribution of the remaining bones. |
| SUVmax；最大標(biāo)準(zhǔn)攝取值 檢查結(jié)論「 |
| SUVmax; maximum standard intake value inspection conclusion |
| 與前對(duì)比： |
| Compared with before: |
| 1.肢腺癌化療后,肢體MT較前相仿，仍FDG代謝異常增高，侵犯左側(cè)腎上腺及胃后壁：新見(jiàn)胸骨、右側(cè)股骨上段轉(zhuǎn)移；新見(jiàn)兩側(cè)鎖骨上淋巴結(jié)轉(zhuǎn)穢可能：兩肺散在小結(jié)節(jié)，密切隨訪。 |
| 1. After chemotherapy for pancreatic cancer, the limb MT was similar as before, but the FDG metabolism was still abnormally high, and the left adrenal gland and the posterior wall of the stomach were invaded: the sternum and the upper part of the right femur were newly found to metastasize; The newly seen bilateral supraclavicular lymph node metastasis is possible: scattered small nodules in both lungs, close follow-up is needed. |
| 2：雙側(cè)上頸部淋巴結(jié)炎性增生；子宮多發(fā)肌瘤可能。 |
| 2: Inflammatory hyperplasia of bilateral upper cervical lymph nodes; multiple fibroids of the uterus is possible. |
| 報(bào)告醫(yī)生：李楠審核醫(yī)生：劉曉晟 |
| Reporting doctor:Nan Li Reviewing doctor: Xiaosheng Liu |
| 報(bào)告日期：2023-01-31 14:14:56審核日期：2023-01-31 16:31:21 |
| Reporting Date: Jan. 31, 2023 14:14:56 Reviewing Date: Jan. 31, 2023 16:31:21 |
| 上海市徐匯區(qū)東安路270號(hào)電話：（021） 64175590-86908復(fù)旦大學(xué)附屬腫病醫(yī)院 |
| No. 270, Dong’an Road, Xuhui District, Shanghai Tel: (021) 64175590-86908 Cancer Hospital Affiliated to Fudan University |
| （本檢查報(bào)告及圖像僅供參考重要資料請(qǐng)妥善保存）tMwfKd C- |
| (This inspection report and images are for reference only, please keep the information properly) |
| m掃描全能王創(chuàng)建 |
|
| 復(fù)旦大學(xué)附屬腫痛醫(yī)院 核醫(yī)學(xué)科 |
| Department of Nuclear Medicine, Cancer Hospital, Affiliated to Fudan University |
| PET 檢查報(bào)告單 |
| PET inspection report |
| 影像號(hào) 11407881 |
| Image number 11407881 |
| 檢查日期 2022/09/15 |
| Inspection date: Sept. 15, 2022 |
| 姓名：*** 性別:女 |
| Name: ***Gender: Female |
| 檢查方式： PET/CT斷層 |
| Inspection method: PET/CT tomography |
| 核素： 18F藥物：FDG |
| Nuclide: 18F Medicine: FDG |
| 申請(qǐng)科室：胰腺外科 |
| Department Application: Pancreatic Surgery |
| 臨床診斷：胰腺癌 |
| Clinical Diagnosis: Pancreatic Cancer |
| 年齡：49 8門診號(hào)：310104197210274823 |
| Age: 49 Clinic No.: 310104197210274823 |
| 檢查部位：全身 床號(hào)：給藥方式：靜脈注射 |
| Examination Area: Whole Body Bed No.: Administration Method: Intravenous Injection |
| 劑量： 5. 285mOI 血糖：10.0mmol/L 注射部位：右手背 |
| Dosage: 5. 285mOI Blood sugar: 10.0mmol/L Injection site: Back of right hand |
| 檢查項(xiàng)目：腫瘤全身斷層顯像檢查排號(hào)，46 |
| Inspection items: Tumor whole body tomography inspection Queue Number: 46 |
| 簡(jiǎn)要病史：體檢發(fā)見(jiàn)多項(xiàng)腫瘤指標(biāo)升高：2022.09. 14本院CT:胰腺體尾部MT，侵及脾動(dòng)靜脈與左腎上腺，請(qǐng)結(jié)合臨床及其他其他檢查。 |
| Brief medical history: Multiple tumor indicators increasing was found in physical examination: Sept. 14, 2022 CT in our hospital: MT of the pancreas body tail, invading the splenic arteriovenous and left adrenal gland, please combine with clinical and other examinations. |
| 胰周、脾門區(qū)數(shù)枚強(qiáng)化淋巴結(jié)，部分稍大，轉(zhuǎn)修待排. |
| There were several enhanced lymph nodes in the peripancreatic and splenic hilum area, some of which were slightly larger. |
| 檢查所見(jiàn)： |
| Examination Results: |
| 禁食狀態(tài)下，靜脈注射F-18-FDQ,休息約60分鐘,行PET/CT顯像,圖像顯示清晰. |
| In the fasting state, F-18-FDQ was injected intravenously, rested for about 60 minutes, and PET/CT imaging was performed, and the images were clearly displayed. |
| 胰體部軟組織腫塊影，約4.2*2.9cm.侵犯左側(cè)腎上腺及胃后壁，放射性攝取異常增 高,SUVmax=4.4： |
| The soft tissue mass shadow in the body of the pancreas is about 4.2 * 2.9 cm. It invades the left adrenal gland and the posterior wall of the stomach, and the radioactive uptake is abnormally high. SUVmax=4.4: |
| 肝臟形態(tài)、大小正常，密度均勻，放射性分布未見(jiàn)明顯異常，肝內(nèi)外膽管未見(jiàn)明顯擴(kuò)張： |
| The shape and size of the liver were normal, the density was uniform, the distribution of radioactivity was normal, and the intrahepatic and extrahepatic bile ducts were not obviously dilated: |
| 膽囊壁未見(jiàn)明顯增厚，未見(jiàn)放射性攝取異常增高灶：脾臟大小正常，放 射性分布均勻： |
| There is no obvious thickening of the gallbladder wall, no abnormally increased radioactive uptake foci: the spleen is normal in size, and the radioactivity is evenly distributed: |
| 腸道各段見(jiàn)少量生理性放射性攝取；右例腎上腹形態(tài)未見(jiàn)明顯異常，未見(jiàn)明顯放射性異常攝??； |
| A small amount of physiological radioactive uptake was seen in each segment of the intestinal tract; no obvious abnormality was seen in the right renicapsule, and no obvious abnormal radioactive uptake was seen; |
| 雙腎實(shí)質(zhì)未見(jiàn)異常密度影及放射性異常增高灶，腎盂、腎盞未見(jiàn)明顯擴(kuò)張：膀胱充盈良好,膀胱壁未見(jiàn)異常密度影；子宮體積增大，左后緣凸起略低密度灶， 約5. |
| There were no abnormal density shadows or abnormally increased radioactive foci in the kidney parenchyma, and no obvious expansion of the renal pelvis and calyces; the bladder was well filled, and no abnormal density shadows were seen in the bladder wall; about |
| 8*4. 1cm,放射性分布缺損；雙側(cè)附件區(qū)未見(jiàn)明顯放射性異常攝?。焊垢购?、兩側(cè)髂血管旁及腹股溝未見(jiàn)明顯腫大淋巴結(jié)。 |
| 5.8*4. 1cm, radioactive distribution defects; no obvious abnormal uptake of radioactivity in the bilateral appendages; no obvious enlarged lymph nodes in the retroperitoneal abdomen, both sides of the iliac vessels or groin. |
| 兩肺紋理清晰，未見(jiàn)實(shí)質(zhì)性病變及放射性攝取異常增高灶，縱隔及兩側(cè)肺門淋巴結(jié)未見(jiàn)明顯腫大及放射性異常攝?。?/td> |
| The texture of both lungs was clear, no substantial lesion and abnormally increased radioactive uptake were found, no obvious enlargement and abnormal radioactive uptake of mediastinal and bilateral hilar lymph nodes were seen; |
| 食管管壁未見(jiàn)明顯增厚及放射性異常增高灶.雙側(cè)孔腺未見(jiàn)異常放射性分布； |
| There was no obvious thickening of the esophageal wall and abnormally increased radioactivity. There was no abnormal radioactive distribution in the bilateral orifice glands; |
| 雙側(cè)腋窩及內(nèi)乳未見(jiàn)明顯腫大淋巴結(jié)及放射性攝取異常增高灶。 |
| There were no obvious enlarged lymph nodes and abnormally increased radioactive uptake foci in the bilateral armpits and inner breasts. |
| 鼻咽頂后壁及兩側(cè)壁未見(jiàn)明顯增厚，咽隱窩及咽旁間隙清晰； |
| There is no obvious thickening of the top and back wall and both sides of the nasopharynx, and the pharyngeal recess and parapharyngeal space are clear; |
| 雙側(cè)上頜竇、篩竇及蝶竇結(jié)構(gòu)未見(jiàn)明顯異常，幼膜未見(jiàn)明顯增厚； |
| Bilateral maxillary sinus, ethmoid sinus and sphenoid sinus structures are normal, and mucosa is not significantly thickened; |
| 口咽部、兩側(cè)梨狀窩、甲狀腺未見(jiàn)明顯異常密度影及放射性異常增高灶，雙側(cè)頸部及鎖骨上淋巴結(jié)未見(jiàn)明顯腫大及放射性異常攝取。 |
| Oropharynx, bilateral pyriform sinuses, and thyroid had no obvious abnormal density shadow or abnormally increased radioactive focus, and bilateral neck and supraclavicular lymph nodes had no obvious swelling and abnormal radioactive uptake. |
| 大腦各葉、雙側(cè)基底節(jié)、丘腦及兩側(cè)小腦放射性分布對(duì)稱，未見(jiàn)明顯放射性攝取異常增高或減低區(qū)： |
| The distribution of radioactivity in the lobes of the brain, bilateral basal ganglia, thalamus, and bilateral cerebellum is symmetrical, and there is no obvious abnormally increased or decreased radioactive uptake area: |
| CT平掃顯示腦實(shí)質(zhì)內(nèi)未見(jiàn)異常密度影，中線結(jié)構(gòu)居中： |
| Plain CT scan showed no abnormal density shadow in the brain parenchyma, and the midline structure was centered: |
| 腦溝、腦裂、腦池未見(jiàn)明顯增寬、擴(kuò)張。 |
| Cerebral sulci, fissures, and brain cisterns were not significantly widened or expanded. |
| 所見(jiàn)骨骼放射性分布未見(jiàn)明顯異常。 |
| There was no obvious abnormality in the distribution of radioactivity in the bones. |
| ■I |
| ■I |
| SUVmax：最大標(biāo)準(zhǔn)攝取值 |
| SUVmax: maximum standard uptake value |
| 檢查結(jié)論： |
| Inspection Results: |
| 胰體部軟組織腫塊影，F(xiàn)DG代謝增高，考慮為MT可能大，侵犯左側(cè)腎上腺及胃后壁. |
| The soft tissue mass in the body of the pancreas and increased FDG metabolism is considered that the MT possibility is high, invading the left adrenal gland and the posterior gastric wall. |
| 子宮肌瘤伴囊變. |
| Uterine fibroids with cystic changes. |
| 報(bào)告醫(yī)生：徐俊彥 |
| Reporting doctor: Xu Junyan |
| 報(bào)告日期：2022/09/15 21:08:27 |
| Date of report: Sept. 15, 2022 21:08:27 |
| trim |
|
| 審核醫(yī)生：胡四龍 |
| Reviewing Doctor: Hu Silong |
| 審核日期：2022/09/16 07:50:18 |
| Review Date: 2022/09/16 07:50:18 |
| 上海市徐匯區(qū)東安路270號(hào) 電話:(021) 64175590-86908(本檢查報(bào)告及圖像僅供參考乖要資料請(qǐng)妥善保存) |
| No. 270 Dong’an Road, Xuhui District, Shanghai Tel: (021) 64175590-86908 (This inspection report and images are for reference only, please keep the important information properly) |
| 復(fù)旦大學(xué)附屬腫皰醫(yī)院 |
| Cancer Hospital Affiliated to Fudan University |
| FwDm Ufilv?r?Jty ShaA?M*l Cmc- |
|
| 復(fù)旦大學(xué)附屬腫瘤醫(yī)院放射診斷報(bào)告(CT) |
| Radiological diagnosis report (CT) of Cancer Hospital Affiliated to Fudan University |
| 姓名： ***性別：女。 |
| Name: *** Gender: Female. |
| 年齡：49歲 病區(qū)：放射學(xué)檢查號(hào)碼：11407881 |
| Age: 49 Ward: Radiology Examination No.: 11407881 |
| 門診號(hào)：310104197210274823 住院號(hào)： 科室：胰腺外科病床 |
| Clinic No.: 310104197210274823 Hospitalization No.: Department: Pancreatic surgery Ded: |
| 臨床診斷：胰尾惡性腫瘤送檢醫(yī)生的要求：胰腺CT（增強(qiáng)） |
| Clinical diagnosis: Malignant tumor of the pancreas tail Doctor’s request for examination: CT of the pancreas (enhanced) |
| 檢查部位和名稱：胰腺CT (增強(qiáng))檢查時(shí)間：2022 -9 -1319:24:20 |
| Examination site and name: Pancreas CT (enhanced) Examination time: Sept. 13, 2022 19:24:20 |
| 檢查方法,厚層5mm間隔5mm【碘】造影劑100ml速率l.5ml/s延時(shí) 動(dòng)脈期22s靜脈期75s |
| Inspection method, thick layer 5mm, interval 5mm [iodine] contrast agent 100ml rate 1.5ml/s delay arterial phase 22s venous phase 75s |
| 放射學(xué)表現(xiàn)胰腺體尾部腫塊.約60*42mm，形態(tài)不規(guī)則,輕中度不均勻強(qiáng)化.病變包繞脾動(dòng)靜 |
| Radiological manifestations: a mass in the tail of the pancreas. About 60*42mm, irregular in shape, with mild to moderate uneven enhancement. The lesion surrounds the spleen |
| 脈與部分左腎上腺.遠(yuǎn)端抵近脾門,局部與胃壁貼鄰.胰周、脾門區(qū)數(shù)枚也強(qiáng)化淋巴結(jié),部分稍大。 |
| artery-vein and part of the left adrenal gland. The distal end is close to the splenic hilum, and some part is adjacent to the stomach wall. Several lymph nodes in the peripancreatic and splenic hilus areas also strengthen, and some are slightly larger. |
| 肝臟大小、形態(tài)正常,肝內(nèi)目前未見(jiàn)明確占位性病變，肝內(nèi)血管走行正常，肝內(nèi)外膽管無(wú)擴(kuò)張。 |
| The size and shape of the liver were normal, no clear space-occupying lesions were found in the liver, the blood vessels in the liver run normally, and the extrahepatic and extrahepatic bile ducts were not dilated. |
| 脾不大，右腎上腺大小形態(tài)及密度正常，雙側(cè)腎臟對(duì)稱。 |
| The spleen was not enlarged, the size, shape and density of the right adrenal gland were normal, and the bilateral kidneys were symmetrical. |
| 大小及形態(tài)正常,未見(jiàn)局灶性密度異常.腹膜后未見(jiàn)腫大淋巴結(jié),腹腔內(nèi)未見(jiàn)積液. |
| The size and shape were normal, and no focal density abnormalities were found. There was no enlarged lymph node in the retroperitoneum, and no effusion in the abdominal cavity. |
| 放射學(xué)診斷： |
| Radiological diagnosis: |
| 胰腺體尾部MT，侵及脾動(dòng)脈與左腎上腺,請(qǐng)結(jié)合臨床及其他檢查。 |
| MT at the tail of the pancreas, invading the splenic artery and left adrenal gland, please combine with clinical and other examinations. |
| 胰周、脾門區(qū)數(shù)枚強(qiáng)化淋巴結(jié)，部分稍大，轉(zhuǎn)移待排，密切隨訪. |
| There were several enhanced lymph nodes in the peripancreatic and splenic hilum area, some of which were slightly larger, and the metastasis was waiting to be excluded. Close follow-up was needed. |
| 報(bào)告醫(yī)師：彭琴 |
| Reporting physician: Qin Peng |
| 報(bào)告時(shí)間：2022-09T4 12:11:13 |
| Reporting time: Sept. 14， 2022 12:11:13 |
| 審核醫(yī)師 |
| Auditing Physician: |
| 審核時(shí)間；2022-09-11 |
| Reviewing Date; 2022-09-11 |
| 15:40:38 |
| 15:40:38 |
| 1.本報(bào)告的僅供性床醫(yī)師參考.2.本報(bào)告為乖要資料，請(qǐng)妥為保管? |
| 1. This report is only for the reference of clinicians. 2. This report is important information, please keep it safe |
|
|
| 復(fù)旦大學(xué)附屬腫瘤醫(yī)院放射診斷報(bào)告（CT） |
| Radiological Diagnosis Report (CT) Of Cancer Hospital Affiliated To Fudan University |
| 姓名：馀東雁性別 女 年齡：50 病區(qū)：,放射學(xué)檢查號(hào)碼：11407881 |
| Name: *** Gender: Female Age: 50 Ward: Radiology Examination No.: 11407881 |
| 門診號(hào)：310104197210274823住院號(hào)：2119695科室：胰腺膽道專病門診病床， |
| Outpatient No.: 310104197210274823 Inpatient No.: 2119695 Department: Outpatient For Pancreas And Biliary Tract Diseases, Bed No.: |
| 臨床診斷：胰尾惡性腫瘤送檢醫(yī)生的要求：胰腺CT （增強(qiáng)） |
| Clinical diagnosis: Malignant tumor of the tail of the pancreas. The doctor’s request for examination: CT of the pancreas (enhanced) |
| 檢查部位和名稱： 胰腺CT （增強(qiáng)）檢查時(shí)間：M2022-11-1510:51:49 |
| Examination site and name: Pancreas CT (enhanced) Examination time:Nov. 15, 2022 10:51:49 |
| 檢查方法：層厚5mm間隔5mm【碘】造影劑100ml速率1.5ml/s延時(shí) 動(dòng)脈期22s 靜脈期75s |
| Inspection method: layer thickness 5mm interval 5mm [iodine] contrast agent 100ml rate 1.5ml/s delay arterial phase 22s venous phase 75s |
| 放射學(xué)表現(xiàn)：對(duì)比2022-9-13前片：胰腺M(fèi)T治療后，胰腺體尾部腫塊較前增大，約58*61mm, |
| Radiological manifestations: Compared with the film got on September 13, 2022: After pancreatic MT treatment, the mass at the tail of the pancreas increased, about 58*61mm, |
| 形態(tài)不規(guī)則，輕中度不均勻強(qiáng)化，病變包繞脾動(dòng)靜脈與部分左腎上腺，遠(yuǎn)端抵近脾門,局部侵犯胃壁。 |
| Irregular in shape, mild to moderate uneven enhancement, the lesion surrounds the splenic artery and vein and partial left adrenal gland, the distal end is close to the splenic hilum, and partially invades the gastric wall. |
| 脾周、脾門區(qū)數(shù)枚強(qiáng)化淋巴結(jié)較前相仿，部分稍大.肝臟大小、形態(tài)正常.肝內(nèi)目前未見(jiàn)明確占位性病變，肝內(nèi)血管走行正常，肝內(nèi)外膽管無(wú)擴(kuò)張. |
| Several enhanced lymph nodes around the spleen and in the splenic hilum area are similar as before, some of them are slightly larger. The size and shape of the liver are normal. There is no definite space-occupying lesion in the liver at present, the blood vessels in the liver are normal, and the intrahepatic and extrahepatic bile ducts are not dilated |
| 脾不大，右腎上腺大小形態(tài)及密度正常.雙側(cè)腎臟對(duì)稱，大小及形態(tài)正常，未見(jiàn)局灶性密度異常.腹膜后未見(jiàn)腫大淋巴結(jié)，腹腔內(nèi)未見(jiàn)積液. |
| The spleen was not enlarged, and the size, shape, and density of the right adrenal gland were normal. The bilateral kidneys were symmetrical, with normal size and shape, and no focal density abnormalities. No enlarged lymph nodes were found in the retroperitoneum, and no fluid was found in the abdominal cavity. |
| 放射學(xué)診斷： |
| Radiological diagnosis: |
| 腴腺M(fèi)T較前增大，侵及脾動(dòng)靜脈與左腎上腺及胃壁. |
| Pancreatic MT was larger than before and invaded splenic artery and vein, left adrenal gland and gastric wall |
| 脾周、脾門區(qū)數(shù)枚強(qiáng)化淋巴結(jié)較前相仿，部分稍大，繼續(xù)隨訪. |
| Several enhanced lymph nodes in the perisplenic and splenic hilum area were similar as before, some were slightly larger, and the follow-up was needed. |
| 報(bào)告醫(yī)師?彭琴審核醫(yī)師： |
| Reporting Physician: Qin Peng Reviewing Physician: |
| 報(bào)告時(shí)間：2022-11-16 12:55:32 審核時(shí)同：2022-11-17 09:55:16 |
| Reporting time: Nov.. 16, 2022 12:55:32 Reviewing time: Nov. 17, 2022 09:55:16 |
| I.本報(bào)告單僅供臨床醫(yī)師參考.2.本報(bào)告為重要要資料，請(qǐng)妥為保管. |
| I. This report is only for reference of clinicians. 2. This report is important information, please keep it safe. |
| m掃描全能王創(chuàng)建 |
|
| 復(fù)旦大學(xué)附屬腫瘤醫(yī)院放射診斷報(bào)告（CT） |
| Radiological Diagnosis Report (CT) Of Cancer Hospital Affiliated To Fudan University |
| 姓名：***性別：女 年齡： 50 病區(qū)：放射學(xué)檢查號(hào)碼，11407881 |
| Name: *** Gender: Female Age: 50 Ward: Radiological Examination No., 11407881 |
| 門診號(hào)：310101197210274823 住院號(hào)：2119695 科室：股腺膽道專病門診病床? |
| Outpatient No.: 310101197210274823 Inpatient No.: 2119695 Department: Femoral gland and biliary tract disease outpatient Bed: |
| 臨床診斷：胰尾惡性腫瘤送檢醫(yī)腳的娜，覷腺CT （增強(qiáng)） |
| Clinical diagnosis: Malignant tumor of the tail of the pancreas The Request of Examination Physican, pancreas CT (enhanced) |
| 檢查部位和名稱?胰腺CT （增強(qiáng)）檢查時(shí)間，2023-01-2808:20:26 |
| Examination site and name: Pancreas CT (enhanced) Examination Time, Jan. 28, 2023 08:20:26 |
| 檢查方法：層厚5mm間隔5mm【碘】造影劑100ml速率l.5ml/s延時(shí) 動(dòng)脈期22s靜脈期75s |
| Inspection method: layer thickness 5mm interval 5mm [iodine] contrast agent 100ml rate 1.5ml/s delay arterial phase 22s venous phase 75s |
| 放射學(xué)表現(xiàn)，對(duì)比2022-11-15前片，腆腺M(fèi)T治療后，膚腺體尾部腫塊大致同前,約48 |
| Radiological manifestations, compared with the previous film on November 15, 2022, After MT treatment of the pancreas, the mass in the tail of the pancreas is roughly the same as before,, about 48 |
| *65mm,形態(tài)不規(guī)則，輕中度不均勻強(qiáng)化，病變包繞脾動(dòng)靜脈與部分左腎上腺，遠(yuǎn)端抵近脾門，局部侵犯胃壁.胰周、脾門區(qū)數(shù)枚強(qiáng)化淋巴結(jié)較前相仿，部分梢大。 |
| *65mm, irregular shape, mild to moderate heterogeneous enhancement, the lesion surrounded the splenic artery and vein and some part of the left adrenal gland, the distal end approached the splenic hilum, and partially invaded the gastric wall. Several enhanced lymph nodes in the peripancreatic and splenic hilum area were similar as before， some of which are larger. |
| 肝臟大小、形態(tài)正常，肝內(nèi)目前未見(jiàn)明確占位性病變，肝內(nèi)血管走行正常，肝內(nèi)外膽管無(wú)擴(kuò)張.脾不大，右腎上腺大小形態(tài)及密度正常.雙側(cè)腎臟對(duì)稱，大小及形態(tài)正常，未見(jiàn)局灶性密度異常,腹膜后未見(jiàn)腫大淋巴結(jié)，腹腔內(nèi)未見(jiàn)積液. |
| The size and shape of the liver are normal, no clear space-occupying lesions are found in the liver, the blood vessels in the liver run normally, and the extrahepatic bile ducts are not dilated. The spleen is not enlarged, and the size, shape and density of the right adrenal gland are normal. , no focal density abnormalities, no enlarged lymph nodes in the retroperitoneum, no effusion in the abdominal cavity. |
| 放射學(xué)診斷； |
| Radiological diagnosis; |
| 胰腺M(fèi)T大致同前，侵及脾動(dòng)靜脈與左腎上腺及胃壁。 |
| Pancreatic MT is roughly the same as before, invading the splenic artery and vein, left adrenal gland and gastric wall. |
| 胰周、脾門區(qū)數(shù)枚強(qiáng)化淋巴結(jié)較前相仿，繼續(xù)隨訪。 |
| Several enhanced lymph nodes in the peripancreatic and splenic hilum area are similar as before, and the follow-up was needed. |
| 報(bào)告醫(yī)師：周嘉音 |
| Reporting physician: Jiayin Zhou |
| 報(bào)告時(shí)間i 2023-01-29 13:17:04 |
| Reporting time: Jan. 29, 2023 13:17:04 |
| 審核醫(yī)師: |
| Reviewing Physician: |
| 審核時(shí)間：2023-01-29 13:23:17 |
| Review time: Jan. 29, 2023 13:23:17 |
| 本報(bào)告單僅供臨床醫(yī)肺參考.2.本報(bào)告為重要資料,請(qǐng)妥為保管. |
| This report is only for clinical reference. 2. This report is important information, please keep it safe. |
| 掃描全能王創(chuàng)建 |
|
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