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医学翻译-出院记录及出院诊断

发表时间:2019-2-8  浏览次数:168  
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Diagnosis and treatment
Repetitive chest drainage was performed to extract the pleural effusion. After that, about 500 ~ 900 ml pleural effusion was extracted per day. Chest and abdominal CT scanning indicated nodule shadow in the superior lobe of left lung. Multiple patch shadow was noted in left lung. Multiple nodule shadows together calcification shadow was also observed in the lower fight lung. Slight interstitial changes were noted in the right pulmonary pleura.Thickening of left pleura was observed. Slight pneumatosis was observed during the chest drainage. Recombinant human interleukin-2 (125Ala, 2MU), cisplatin (20mg) and recombinant human interleukin-2 (125Ala, 3MU) were injected via intrathoracic injection, respectively.

Discharge diagnosis:
Poorly differentiated adenocarcinoma in the left lung [cTxN0M1a, stage IV, epidermal growth factor receptor (EGFR) mutation negative].
Pleural effusion was noted.
The patient received 2 cycles of chemotherapy [Pemetrexed (Alimta) plus cisplatin]
Deterioration was noted in pleuroiasis.

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