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病歷中英文翻譯模板

發(fā)表時間:2021/07/30 00:00:00  瀏覽次數(shù):1187  
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原文
影像學(xué)表現(xiàn):
冠狀及矢狀面示垂體上下徑為11mm,信號欠均勻。垂體柄增粗,并形成結(jié)節(jié);垂體上方偏左側(cè)見一小圓形長T1、稍長T2異常信號影,界限清楚。動態(tài)增強掃描早期正常垂體明顯強化,垂體內(nèi)病灶輕度強化,呈相對低信號,大小約6mmX5mm。鞍底無明顯下陷,鞍旁及鞍上其它結(jié)構(gòu)未見異常。
頭顱大小、形態(tài)未見異常。垂體窩見小圓形長T1稍長T2異常信號影,余腦實質(zhì)未見異常信號灶,灰白質(zhì)界限清楚。各腦室大小、形態(tài)正常。腦溝、腦裂、腦池未見增寬。中線結(jié)構(gòu)居中。顱骨未見異常信號。右側(cè)上頜竇粘膜增厚。
影像學(xué)診斷:
1. 垂體結(jié)節(jié)影,并垂體柄增粗,考慮良性病變,組織細胞增生癥可能性大,累及左側(cè)視交叉,與2012-06-29MR片比較,未見明顯變化。
2. 右側(cè)上頜竇炎。

譯文
Findings: 
On the coronal and sagittal images, the superior-inferior axis of the pituitary gland was 11mm, and the signals were heterogeneous. The pituitary stalk was thickened, and tuberosis was noticed; a small round long T1 and slightly long T2 abnormal signal with well-defined border was seen in the left upper pituitary gland. At the early stage of dynamic contrast enhanced scan, the normal pituitary gland was significantly enhanced. A mild enhanced lesion (about 6mm*5mm) with relative hypointensity was observed in the pituitary gland. No significantly sagged sellar floor was noted. No abnormality of the metasellar and suprasellar structures was observed.
The size and shape of the cranium was normal. Small round long T1 and slightly long T2 abnormal signals were seen in the hypophysial fossa, no abnormal signal lesion was seen in the other part of cerebral parenchyma, and the border between the grey matter and the white matter was well-defined. The size and shape of each cerebral ventricle were normal. The cortical sulci, schizencephaly and cistern were not widened. The median line was normal. No abnormal signal was seen in the skull. The right mucous membrane of maxillary sinus was thickened.
Iconographic diagnosis:
1. Pituitary gland nodule combined with thickened pituitary stalk, based on which, a benign lesion, histocytosis, is speculated, with the left optic chiasma involved. Compared with the MR images obtained on June 29, 2012, no significant change is noticed.
2. Right maxillary sinusitis.

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