肺部CT检查报告中英 模板

肺部CT作为肺癌诊断的一种常规手段,是国外就医必须的材料之一。与MRI,PET/CT等材料一起涵盖在影像学分类中。在向国外医院提供该部分材料时,准确地做法是将带文字的材料进行 ,然后将胶片进行拍照(白天用高清相机,对着白墙拍照)。以pdf格式或dicom格式发给国外医生。针对文字 部分,现提供几个样例,供大家参考。


原文:
骶前区可见多发淋巴结,大者短径约1.0 cm (图2-60〕,余腹盆腔及腹膜后、双侧腹股沟区未见明确肿大淋巴结。
肝脏可见多发结节及肿物, 大者约4.6 X 3.9 cm (图2-6〕,边界欠清。
双肾多发低密度灶,大者约1.3 cm,界淸。
胆囊、胰腺、脾脏、副脾结节、双侧肾上腺、膀胱、前列腺、双侧精囊腺未见明确异常。
未见腹水征象。
“直肠癌”参阅2016-3-15胸部CT图像:
1、图2-25所示右肺小结节较前略有缩小,约0.3 cm。图2-39左下肺小类结节大致同前。右肿中叶斑片影同前相仿。
2、余双肺未见明确新病灶。
3、纵隔淋巴结、肺门淋巴结未见明确肿大淋巴结。
4、双侧胸腔、心包未见积液。
5、扫描范围内肝内可见多发结节及肿物较前缩小,边界模糊,大者约3.4*2.5 cm〔图57〉,请结合腹部检查。

译文:
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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