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1、编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第9页 共9页1.头颅骨质未见异常Theshapeandthesizeoftheskullarenormal。Theinnerandoutertables，andthediploeofthecranialvaultareunremarkable，onthelateralview，thesizes，theshapeandthedensityofthesellaturcicaarenothingremarkable。Impression：plainfilmsoftheheadarenormal.2.头颅正常APandlateralv
2、iewsoftheskullaresubmitted.Thecavariumhasnormalconfigurationandappearance.Thereisnoevidenceoffracture.Thesofttissuesarenormal.Impression:Normalskull.3.鼻旁窦炎症Thereisgeneralizedhazinessofthefrontal,ethmoidandbilateralmaxillarysinuses.Findingsareconsistentwithsinusitis.Impression:Frontal,（额窦）ethmoid（筛）a
3、ndmaxillary（上颌）sinusitis.4.右膝关节正常Thebonesandjointsoftherightkneearenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Thereisnojointeffusion.Impression:Normalrightknee.5.右膝退变Thebonesandjointsoftherightkneearenormal.Milddegenerativechangesofthekneejointispresent.Thereisnoevidence
4、offractureorsubluxation.Thesofttissuesarenormal.Thereisnojointeffusion.Impression:MildDJDofkneejoint。6.左小腿蜂窝炎，（软组织肿胀，无骨髓炎）Thereismilddegreeofsofttissueswelling10.9cmattheproximalanteriorleg.Thereisnoevidenceofadjacentboneabnormality.Thereisnoevidenceofperiostealreaction.Thefibularbonehasnormalconfig
5、urationandappearance.Impression:Thereisafocal10.9cmlengthsofttissueswellingattheproximalanteriorlegadjacenttothetibia.Thetibialbonehasnormalconfigurationwithnoevidenceofosteomyelitis.Findingsareconsistentwithlocalizedcellulitis.7.右侧胫骨石膏固定中，位置可，和老片比较相似Therightlegisinaplastercast.Thereisobliquefractur
6、eoftherightmidtibialshaft.Thereismildcallousformationacrossthefractureline.Thebonefragnmentsareinproperalignment.Comparisonwithpreviouseximinationof4/19/2006revealsnosignificantintervalchange.Impression:S/Pfractureoftherightmidtibialshaft.Callousformationispresentacrossthefractureline.Thereisnointer
7、valchangefrompreviousstudyof4/19/2006.8.右足正斜位正常Thebonesandjointsoftherightforefootarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Impression:Normalrightforefoot.9.正常左踝正侧位APandlateralviewsoftheleftanklewereobtained.Thebonesandjointsoftheanklearenormal.Thereisnofracture.Impr
8、ession:Normalleftankle.10.右侧足背距骨和舟状骨之间退变Thebonesandjointsoftherightforefootarenormal.Milddegenerativechangesofthetalo-navicularjointispresent.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Impression:Normalrightforefoot.MildDJDoftalo-naviculatjoint.11.双侧足背斜位，拇外翻Thereismilddegreeofh
9、alluxvalgusdeformitiesofthebothfeetrightandleft.Thebonesandjointsoftherestofthefeetareunremarkable.Softtissuesarewithinnormallimits.Impression:1.Mildrighthalluxvalgusdeformities.Thebonesandjointsofbilateralelbowsarenormal.Thesofttissuesarenormal.Thereisnoevidenceoffractureorsubluxation.Impression:No
10、rmalelbows.13.右侧拇指正常Thebonesandjointsoftherightthumbarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Impression:Normalrightthumb.14.右肩关节正位正常Thebonesandjointsoftherightshoulderarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Impression:Normalrightsh
11、oulder.15.右腕正侧位正常Thebonesandjointsoftherightwristarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Impression:Normalrightwrist.16.双侧腕关节（右侧正常，左侧横行骨折，未移位）Thereisatransversenondisplacedfractureoftheleftdistalradialmetaphysisregion.Theleftwristisnormalinconfigurationandappearanc
12、e.Therightdistalforearmandrightwristarenormalinappearance.Softtissuesarewithinnormallimits.Impression:Transversenondisplacedfractureoftheleftdistalradialmetaphysis.Rightdistalforearmandwristarenormal.Thebonesandjointsofthelefthandarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesareno
13、rmal.Impression:Normallefthand.18.正常锁骨片（左）Theleftclaviclehasnormalconfigurationandappearance.Thesofttissuesoftheneckabovetheclavicleisnormlainappearance.Scapularandleftshoulderjointarewithinnormallimits.Noevidenceofsofttissuemassisdemonstrated.Impression:Normalleftclavicle.19.左锁骨及肩胛骨APviewsoftheleft
14、shoulderandscapularevealnormalbonesandjoints.Thereisnoevidenceoffractureorboneabnormality.Thesofttissuesarenormal.Impression:Normalleftshoulderandscapula.20.腹部立卧位正常片Supineanduprightviewsoftheabdomenaresubmitted.Thebowelgaspatternisnormal.Thereisnoevidenceofintestinalobstruction.Thereisnoevidenceofab
15、normalcalcificationsoverlyingthekidneysorthepelvis.Theosseousstructuresarenormal.Impression:Normalabdomen.21.腹部立位正常：Thebowelgaspatternisnormal.Thereisnoevidenceofabnormalcalcifications.Theosseousstructuresarenormal.Impression:Normalabdomen.22.腹部立位大便APerectviewoftheabdomenrevealfecesfilledcolon.There
16、isnoevidenceofabdominalmassorcalcifications.Theosseousstructuresarenormal.Impression:Fecesimpactedcolon.23.颈椎增生性改变Thealignmentofcervicalvertebraisnormal.Curveofthecervicalvertebraexist（disappear）.NarrowingoftheintervertebalspacebetweenC？andc？isfound.Slightosteophytesarerevealedattheposterior/anterio
17、rofC？c？.Thereisnofractureordislocation.24.胸椎增生性改变Thealignmentofthoracicvertebraisnormal.Curveofthecervicalvertebraexist（disappear）.Narrowingoftheintervertebalspacebetweent？andt？isfound.Slightosteophytesarerevealedattheposterior/anterioroft？t？.Thereisnofractureordislocation.Impression:Hyperplasychang
18、esofthethoracicvertebra.25.颈椎正常Thealignmentofcervicalvertebraisnormal.Curveofthecervicalvertebraexist.Theintervertebalspacebetweenthecervicalvertebraisnormal.Noosteophytesarerevealedatthecervicalvertebrabodies.Impression:Normalofthecervicalvertebra.26.胸椎正常Thealignmentofthoracicvertebraeisnormal.Curv
19、eofthethoracicvertebraeexist.Theintervertebalspacebetweenthethoracicvertebraisnormal.Noosteophytesarerevealedatthethoracicvertebrabodies.Impression:Normalofthethoracicvertebra.27.腰椎正常Thealignmentoflumbarvertebraeisnormal.Curveofthelumbarvertebraeexist.Theintervertebalspacebetweenthelumbarvertebraisn
20、ormal.Noosteophytesarerevealedatthelumbarvertebrabodies.Impression:Normalofthelumbarvertebra.28.颈椎退行性变Thealignmentofcervicalvertebraisnormal.Curveofthecervicalvertebradisappear.NarrowingoftheintervertebalspacebetweenC？andc？斜位片有椎间孔狭窄时：Thesecauseminimalnarrowingoftheintervertebralforamina.Severeosteop
21、hytesarerevealedattheposterior/anteriorofC？c？Thereisnofractureordislocation.Impression:Degenerativeofthecervicalvertebra.29.腰椎退行性变Thealignmentoflumbarvertebraisnormal.Curveofthelumbarvertebradisappear.Narrowingoftheintervertebalspacebetweenl？andl？斜位片有椎间孔狭窄时：Thesecauseminimalnarrowingoftheinterverteb
22、ralforamina.Severeosteophytesarerevealedattheposterior/anteriorofl？l？Thereisnofractureordislocation.Impression:Degenerativeofthelumbarvertebra.30.胸片正侧位正常PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralple
23、uralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.Impression:NormalChest31.胸片正位正常PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Th
24、emediastinumandbilateralhilaarenormal.Impression:NormalChest32.胸片有钙化点无其它肺部疾病。PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Asmallcalcifiedatthetopoftherightlung.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Them
25、ediastinumandbilateralhilaarenormal.Impression:Smallcalcifiedatthetopoftherightlung.Noacutelungdisease.33.胸部小结节。PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.Thereisasmalllungnodule3mmsizeattherightmidlung.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal
26、.Themediastinumandbilateralhilaarenormal.Impression:3mmnoduleatrightmidlung.SuggestcomparisonwitholdCXRtoensurestability,otherwisesuggestCTchest.34.两肺纹理增多，未见明显感染之征象。APviewofthechestwasobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Mildincreaseoflungmarkingsarepresent.
27、Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.Impression:Mildincreaseoflungmarkings.Nofocalinfiltrateisseen.35.胸片侧位，肋骨骨折Bilaterallungsarenormal.Thehearthasnormalsizeandcontour.Themediastinumisnormal.Thereisafractureofright7
28、thaxillaryrib.Impression:1.Lungsarenormal.2.Fractureoftheright7thaxillaryrib.36.胸部正侧位（右隔抬高，原因待查）PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.。Thereisele
29、vationofrightseptumImpression:Thereiselevationofrightseptum,suggestfurthercheckup;37.心影稍增大（胸片正位）PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thereismildcardiomegaly.Themediastinumandbilatera
30、lhilaarenormal.Impression:Mildcardiomegaly.Lungsareclear.38.左上肺陈旧性肺结核PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewellexpanded.Thereisfibro-calcificchangesatleftupperlobe.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaaren
31、ormal.Impression:LULpostTBinflmmatoryresiduals.39两肺门增大，建议ct检查PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.Thereismildincreaseofinterstitiallungmarkingswithbilateralprominenthila.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateral
32、hilaarenormal.Impression:Thereismildincreaseofinterstitiallungmarkingswithbilateralprominenthila.SuggestCTchest.40.两肺纹理增多，左侧胸腔积液，心影中度扩大。PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewellexpanded.ThereismildincreaseofinterstitiallungmarkingsandKerley-Blinesatrightlowerlung.Thereisincreased
33、hazeattheLLLsuggestpleuraleffusion.Bilateralapicesarenormal.Thereismoderatecardiomegalywithlargerightatrium.Themediastinumandbilateralhilaarenormal.Impression:Increasedlungmarkingsatlungbases.Leftpleuraleffusion.Moderatecardiomegaly.41.肺感PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewelle
34、xpanded.Thereisdiffuseinterstitialinfiltratesatleftlung/rightlung/LUL?LLL/RUL/RLL.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.Impression:Pneumoniaofleftlung/rightlung/LUL/LLL/RUL/RLL.42.心包积液PAandlateralviewsofthechestwere
35、obtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiacsizeisenlargedwithwaterbottleappearancesuggestingpericardialeffusion.Themediastinumandbilateralhilaarenormal.Impression:Enlargedheartwithwaterbottleappear
36、ancesuggestiveofpericardialeffusion.Nolunginfiltrateisseen.43.右上肺肉芽肿PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal
37、.A3mmgranulomaisseenatRUL.CXR.Impression:3mmgranulomaatRUL.Suggest6monthfollowup44.正常骨盆及两侧髋部Theiliacbonesarenormalinconfigurationandappearance.Bilateralhipjointsarenormalinappearance.Thereisnoevidenceofhipjointdysplasia.Bilateralproximalfemursarenormalinappearance.Softtissuesarenormal.Impression:Nor
38、malpelvisandbilateralhips.45.两侧髋部正常Froglateralviewsofthehipsaresubmitted.Bothacetabulumarenormalinappearance.Thefemoralheadsarenormal.Thereisnosubluxation.Impression:Normalhips.46.右侧肋骨正常Therightribshavenormalconfigurationandappearance.Thereisnofracture.Nopleuraleffusionoftheipsilateral.Impression:No
39、rmalrightribs.47.第一趾骨骨折Right1sttoe:APandobliquesoftheright1sttoearesubmitted.Thereisasmallavulsion（撕脱）fractureatthemedialbaseofthedistal（远侧的）/proximal(近侧的)phalangeTheIPjoint（趾间关节）isnormal.Thesofttissuesarenormal.Impression:Smallavulsionfractureatthemedialbaseofthedistalphalange.48.左侧第五蹠骨基底部撕脱性骨折Thereisaavulsionfractureatthebaseoftheleft5thmatatarsalbonewithadjacentsofttissueswelling.Therestoftheleftfootisnormal.Impression:Avulsionfractureatbaseoftheleft5thmetatarsalbone.第 9 页 共 9 页