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首页 各科英文病历集锦妇科英文病历

各科英文病历集锦妇科英文病历.doc

各科英文病历集锦妇科英文病历

bcchen
2018-09-05 0人阅读 举报 0 0 暂无简介

简介:本文档为《各科英文病历集锦妇科英文病历doc》,可适用于医药卫生领域

CASEMedicalNumber:GeneralinformationName:YueJunrongAge:FortytwoyearsoldSex:FemaleRace:HanOccupation:UnemploymentNationality:ChinaMaritalstatus:MarriedAddress:XiaochangcountyofXiaogancityinHubeiTel:Dateofadmission:Febth,Dateofrecord:pm,Febth,Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Thepatientwasfound“myomaofuterus”overtwoyearsagoandmenometrorrhagiaformonthsPresentillness:In,thepatientwasfound“myomaofuterus”inaphysicalexaminationButshehadnothinguncomfortableandhercatameniawasnormalSheusedsomeChinesetraditionalmedicineAboutmonthsago,shefoundthecycleofhercatameniawasshortenfromdaystodaysandtheperiodlastedfromdaystodaysShefeltnopainandthequantitywasnormalShewasacceptedinourhospitalandherdiagnosiswas“subserousmyomaofuterus”Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormalDefecationandurinationarenormal,tooPasthistoryOperativehistory:NeverundergoinganyoperationInfectioushistory:NohistoryofsevereinfectiousdiseaseAllergichistory:ShewasnotallergictopenicillinorsulfamideRespiratorysystem:NohistoryofrespiratorydiseaseCirculatorysystem:NohistoryofprecordialpainAlimentarysystem:NohistoryofregurgitationGenitourinarysystem:NohistoryofgenitourinarydiseaseHematopoieticsystem:NohistoryofanemiaandmucocutaneousbleedingEndocrinesystem:NoacromegalyNoexcessivesweatsKineticsystem:NohistoryofconfinementoflimbsNeuralsystem:NohistoryofheadacheordizzinessPersonalhistoryShewasborninHubeionJulyth,andalmostalwayslivedinWuhanShegraduatedfromseniorhighschoolHerlivingconditionsweregoodNobadpersonalhabitsandcustomsMenstrualhistory:ThefirsttimewhenshewasLastingdayseverytimesanditscycleisaboutdaysObstetricalhistory:Pregnacytimes,oncenatureproduction,inducedabortiontwiceContraceptivehistory:NotclearFamilyhistory:HisparentsarebothalivePhysicalexaminationT℃,Pmin,Rmin,BPmmHgSheiswelldevelopedandmoderatelynourishedActivepositionTheskinwasnotstainedyellowNocyanosisNopigmentationNoskineruptionSpiderangiomawasnotseenNopittingedemaSuperficiallymphnodeswerenotenlargedHeadCranium:HairwasblackandwelldistributedNodeformitiesNoscarsNomassesNotendernessEar:BilateralauriclesweresymmetricandofnomassesNodischargeswerefoundinexternalauditorycanalsNotendernessinmastoidareaAuditoryacuitywasnormalNose:NoabnormaldischargeswerefoundinvetibulumnasiSeptumnasiwasinmidlineNonaresflaringNotendernessinnasalsinusesEye:BilateraleyelidswerenotswellingNoptosisNoentropionConjunctivawasnotcongestiveSclerawasanictericEyeballswerenotprojectedordepressedMovementwasnormalBilateralpupilswereroundandequalinsizeDirectandindirectpupillaryreactionstolightwereexistentMouth:Oralmucousmembranewassmooth,andofnoulcerorerosionTonguewasinmidlinePharynxwasnotcongestiveTonsilswerenotenlargedNeck:SymmetricandofnodeformitiesNomassesThyroidwasnotenlargedTracheawasinmidlineChestChestwall:VeinscouldnotbeseeneasilyNosubcutaneousemphysemaIntercostalspacewasneithernarrowednorwidenedNotendernessThorax:SymmetricbilaterallyNodeformitiesBreast:SymmetricbilaterallyNeithernipplesnorskinwereretractedElasticitywasfineLungs:RespiratorymovementwasbilaterallysymmetricwiththefrequencyofminThoracicexpansionandtactilefremitusweresymmetricbilaterallyNopleuralfrictionfremitusResonancewasheardduringpercussionNoabnormalbreathsoundwasheardNowheezesNoralesHeart:NobulgeandnoabnormalimpulseorthrillsinprecordialareaThepointofmaximumimpulsewasinthleftintercostalspaceinsideofthemidclavicularlineandnotdiffuseNopericardialfrictionsoundBorderoftheheartwasnormalHeartsoundswerestrongandnosplittingRateminCardiacrhythmwasregularNopathologicalmurmursAbdomen:FlatandsoftNobulgeordepressionNoabdominalwallvaricosisGastralintestinaltypeorperistalseswerenotseenTherewasnottendernessandreboundtendernessonabdomenorrenalregionLiverwasnotreachedSpleenwasnotenlargedNomassesFluidthrillnegativeShiftingdullnessnegativeBorhorygmusminNovascularmurmursExtremities:NoarticularswellingFreemovementsofalllimbsNeuralsystem:PhysiologicalreflexeswereexistentwithoutanypathologicalonesGenitourinarysystem:NotexamedRectum:notexanedInvestigationBloodRt:HbglRBCTlWBCGlUrineRt:SGpHBultrasound:subserousmyomaofuteruspositionofloopisnormalHepaticfunction:NormalPTAPTT:NormalProfessionalExaminationPudendum:MarriedtypeVagina:unobstructed,secretionisexcessive,whiteandropyOsofcervix:Nobleeding,slightanabrosisBodyofuterus:Biglikeafistofman,hardanditssurfaceissmoothOthers:NormalHistorysummaryPatientwasfemale,yearsoldThepatientwasfound“myomaofuterus”overtwoyearagoandmenometrorrhagiaformonthsNospecialpasthistoryPhysicalexaminationshowednoabnormityinlung,heartandabdomanProfessionalexaminationcanbeenseenaboveinvestigationinformation:seeaboveImpression:subserousmyomaofuterusSignature:HeLin()

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