胸部疾病医学影像学汉、英诊断报告书示范

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胸部疾病医学影像学汉、英诊断报告书示范

1. 正常胸部平片(平片)  

2.右上肺结核伴空洞形成(平片)  

3.左支气管肺癌(平片)

4.胸腺瘤(平片)  

5.正常胸部C7(CT)  

6.右侧胸腔积液(CT)   

7.右上肺癌(DSA))





1.检查名称：胸部平片.                       检查方法：后前位投照.

表现：两肺清晰。心脏、横膈及片上所显示肋骨均未见异常.

诊断：胸部后前位片未见异常

Name of Examination: Plain chest radiography.   Technique: Postero-anterior projection.

Findings: Both sides of the lung field  are  clear．  Shadows  of  the  heart， the diaphragms，the mediastinum，and the visible ribs are nothing remarkable.

Diagnosis:Normal P-A chest film.



2.检查名称:胸部平片.                   检查方法:后前位投照.

表现:右上肺可见多发片状病灶,部分病灶边界模糊,部分病灶边界清晰,其中最大病处内有一含液平的透亮区,符合空洞表现.此外,还可见致密条索状阴影(纤维化)及两个高密度小结节(钙化).心脏及纵隔未见异常.

诊断：右上肺结核伴空洞形成。

Name of Examination: Plain chest radiography.        Technique: Postero—anterior projection.

Findings: Multiple patchy lesions are revealed in the right upper lung,some of them have ill-defined  

margin and some of them have well-defined margin,inside the largest lesion a round transparent area  with a fluid level compatible with a cavity is revealed．Several dark st**es(fibrosis)and two small high density nodules(calcification) are also seen．No abnormality of the heart and the mediastinum is visible．

Diagnosis：Pulmonary tuberculosis with cavity formation in the right Upper lobe.



3.检查名称L胸部平片.                 检查方法:后前位投照.左侧位投照.

表现:正位胸片见左侧中、上肺野透亮度减低.与左肺门上方相连,可见一4-5cm大小的圆形块影,其边缘有两个切迹.气管向同侧移位.侧位片上块影之半与肺门影重叠.沿整个前胸壁,即胸骨后方,可见一5cm宽的密度增高带.此高密度带的后侧边缘相当于斜裂，呈凹面向后下之弧线形。右肺清晰。

诊断:左肺门区肿块,伴左上肺不张,最可能为支气管肺癌,建议胸部CT检查.

Name of Examination：Plain chest radiography

Technique: Postero-anterior and left lateral projection

Findings:On the frontal view the transparency of the upper and middle fields of the left lung is decreased．A 4-5cm sized round opaque mass lesion with a well-definded margin and two notches is revealed．The medial side of the mass is connected with left upper lung hilum. Ipsilateral(or homo1ateral)deviation of the trachea is showed. On the 1ateral film half of the  mass lesion overlaps on the shadow of hila. There is a 5 cm wide zone of increased density all the way along  the anterior chest wall,behind the sternum. The posterior margin of the high density zone  corresponding to the left oblique fissure is curvilinear with the concaved side faced posteriorly and inferiorly. The right lung field is clear.

Diagnosis:A mass lesion connected with the left hilum and left upper lobe lung collapse is  demonstrated．  The most  1ikely  diagnosis  is  bronchogenic carcinoma．CT examination of the chest is suggested．



4.检查名称:胸部平片.                   检查方法:后前位及右侧位投照

表现:右上纵隔可见一边界光滑而清楚的块影,凸人右侧肺野约4cm.病灶两端与纵隔所形成之两夹角为钝角.右侧位片显示病灶位于前纵隔.两肺野清晰,心,横隔正常。

诊断：右前纵隔肿瘤,最可能为胸腺瘤.

Name of Examlnation: Plain chest radiography.    Technique：Postero-anterior and right later projection.

Findings: A mass lesion with a smooth,well-defined margin from the right upper mediastinum protrudes into the right lung field for around 4cm．The angles formed by two ends of the lesion and the mediastinum are obtuse.The right lateral view shows that the lesion is located in the anterior mediastinum. Both sides of the lung field are clear. Appearances of the heart and both diaphragms are normal．

Diagnosis:Right anterior mediastinal tumor,the most likely dignosis is thymoma.



5.检查名称：胸部增强前后CT扫描     检查方法：静脉团注法注入300mgI／ml碘普罗胺600ml之前和之后，分别进行全胸部横断面CT扫描，层厚10mm，间隔10mm。

表现：胸腔及心包未见积液征象。肺部未见结节状影，两肺未见异常改变，肺门正常oJL、脏大小正常。纵隔淋巴结未见肿大。上腔静脉及主动脉未见异常(未见血栓征象)。右颈内静脉较粗，属正常变异。

诊断：1．胸部CT未见异常。2．右颈内静脉较粗，属正常变异。

Name of Examination：CT scan of the chest(pre and post—enhancement)        Technique：Multiple 10 mm cuts taken with 10 mm apart contiguously in the transaxial plane through the chest have been obtained before and after  the  bolus  intravenous  injection  of 100 ml 300 mgl/ml Iopromide(U1travist).

Findinds：There  is  no  evidence  of pleural  effusion  or  pericardial effusion．  No pulmonary  nodule  is  identified．  No  abnormality  is  present  in  the  1ungfields．  The  hila  are  normal．  The  heart  is  within  normal  1imits.  No mediastinal adenopathy is noted．The superior vena cava and the aorta are normal  (no  evidence  or  thrombus)．  The  right  internal  jugular  vein  is dominant(a normal variation)．

Diagnosis:1. N0 evidence of the chest abnormality.

2. D0minant right internal jugular vein which normal Variation.



6.检查名称:胸部增强前后CT扫描.    检查方法:采用GE 9800CT扫描机作胸部扫描。静脉团注法注入100m1300mgl/ml作离子型造影剂之前和之后，从两肺尖至两侧横膈作胸部连续横断面扫描，层后3mm，间隔3mm。选用肺窗、软组织窗和骨窗观察。

表现：右肺底至右上肺野的每一层面上，都可见新月形均匀的水样密度影与右后胸壁相连。此水样密度影的最宽径达4cm。右肺受压，纵隔轻度左移。左肺清晰。纵隔内未见异常密度影。

诊断：右侧胸腔积液，原因待查。

Name of Examination:CT scan of the chest, pre-and post-enhancement   

Technique:scan of the chest was performed with a GE 9800 scanner．3mm axial slices with 3mm apart were obtained continuously from the top of the lung through both entire hemidiaphragms before and after the bolus intravenous injection of l00ml of non—ionic contrast media(300mgl/m1).Lung，soft tissue and bony windows were displayed.

Findings:A homogeneous watery density crescent zone merged into  the shadow of right  posterior  chest  wall is been on each cut from the bottom to the upper part of the right lung.The width of the widest part of the zone is 4cm.The right lung is compressed. The mediastinum is slightly  shifted to the left.The left lung is clear. No abnormal density can be seen in the mediastinum．

Diagnosis：Right pleural effusion is found．Its cause should be detected further．



7.检查名称:右支气管动脉数字减影血管造影.      检查方法:局部麻醉下,以Seldinger技术,将5F导管插入右股动脉，然后将导管选择性引入右支气管动脉.摄取蒙像后,以4m1/s的速度注入造影剂(碘海醇300mgl/mgl),每次注射总量为10ml.造影剂注射1s后开始摄片,2帧/s,共历15s.先作正位造影,再行侧位造影.

表现:右支气管动脉起自胸主动脉.右上肺肿块病变周围见支气管动脉分支增多,病灶周边部可见细小扭曲不规则小血管，符合肿瘤血管。动脉晚期和微血管期见到病灶造影剂染色(即肿瘤染色)，静脉期未见异常引流静脉。

诊断：右肺上叶癌肿。

Name of Examlnation: DSA of right bronchial artery.

Technique:A F5 catheter was introduced into the right femoral artery with Seldingers technique under local anesthesia.Thereafter,the catheter was introduced selectively into the right bronchial artery．After taking the mask image，serial images were obtained one second after the  injection of the contrast medium(300mgl/ml，Iohexol) in a dose of 10 ml at a speed of 4 ml per second． The frontal view was performed first and the lateral view was succeeded．

Findings: The images show that the right bronchial artery is originated from the thoracic aorta.Some increased branches of the bronchial artery are seen in the  right  upper  1ung  surrounding  a  mass lesion.A few twisted small irregular  vessels  compatible with the tumor vessels are revealed in the pe**heral zone inside the mass lesion.In the late  arterial  phase  and capillary  phase  contrast medium  stain  of the mass  1esion，i.e．the tumor stain,can  clearly be observed.In the venous phase no  abnormal draining vein is visible．

Diagnosis： Carcinoma of the upper of the right lung．

[ 本帖最后由 wuyaxin 于 2008-1-4 14:07 编辑 ]

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