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首页 各科英文病历集锦外科英文病历

各科英文病历集锦外科英文病历.doc

各科英文病历集锦外科英文病历

bcchen
2018-09-05 0人阅读 举报 0 0 0 暂无简介

简介:本文档为《各科英文病历集锦外科英文病历doc》,可适用于医药卫生领域

CASEMedicalNumber:GeneralinformationName:WangRunzhenAge:FortythreeSex:FemaleRace:HanOccupation:TeacherNationality:ChinaMaritalstatus:MarriedAddress:NO,HangkongRoad,JiefangRvenue,Hankou,HubeiTel:Dateofadmission:Janst,Dateofrecord:Am,Janst,Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:RightbreastmassfoundformorethanhalfamonthPresentillness:Halfamonthago,thepatientsuddenlyfeltpaininherrightchestwhensheputupherhandAftertouchingit,shefoundamassinherrightbreast,butnotendness,andthepatientdidn’tpayattentionitThenthepainbecamemoreandmoreserious,sothepatientwenttotumourhospitalandreceivedapathologycentesisHerdiagnosiswasbreastcancerThenshecametoourhospitalandaskedforanoperationSinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormalDefecationandurinationarenormal,tooPasthistoryOperativehistory:NeverundergoinganyoperationInfectioushistory:NohistoryofsevereinfectiousdiseaseAllergichistory:ShewasnotallergictopenicillinorsulfamideRespiratorysystem:NohistoryofrespiratorydiseaseCirculatorysystem:NohistoryofprecordialpainAlimentarysystem:NohistoryofregurgitationGenitourinarysystem:NohistoryofgenitourinarydiseaseHematopoieticsystem:NohistoryofanemiaandmucocutaneousbleedingEndocrinesystem:NoacromegalyNoexcessivesweatsKineticsystem:NohistoryofconfinementoflimbsNeuralsystem:NohistoryofheadacheordizzinessPersonalhistoryShewasborninWuhanonNovth,andalmostalwayslivedinWuhanShegraduatedfromseniorhighschoolHerlivingconditionsweregoodNobadpersonalhabitsandcustomsMenstrualhistory:ThefirsttimewhenshewasLastingtodayseverytimesanditscycleisaboutdaysObstetricalhistory:Pregnacytimes,oncenatureproduction,abortiontwiceContraceptivehistory:NotclearFamilyhistory:HisparentshavebothdiedPhysicalexaminationT℃,Pmin,Rmin,BPmmHgSheiswelldevelopedandmoderatelynourishedActivepositionTheskinwasnotstainedyellowNocyanosisNopigmentationNoskineruptionSpiderangiomawasnotseenNopittingedemaSuperficiallymphnodeswerenotenlargedHeadCranium:HairwasblackandwelldistributedNodeformitiesNoscarsNomassesNotendernessEar:BilateralauriclesweresymmetricandofnomassesNodischargeswerefoundinexternalauditorycanalsNotendernessinmastoidareaAuditoryacuitywasnormalNose:NoabnormaldischargeswerefoundinvetibulumnasiSeptumnasiwasinmidlineNonaresflaringNotendernessinnasalsinusesEye:BilateraleyelidswerenotswellingNoptosisNoentropionConjunctivawasnotcongestiveSclerawasanictericEyeballswerenotprojectedordepressedMovementwasnormalBilateralpupilswereroundandequalinsizeDirectandindirectpupillaryreactionstolightwereexistentMouth:Oralmucousmembranewassmooth,andofnoulcerorerosionTonguewasinmidlinePharynxwasnotcongestiveTonsilswerenotenlargedNeck:SymmetricandofnodeformitiesNomassesThyroidwasnotenlargedTracheawasinmidlineChestChestwall:VeinscouldnotbeseeneasilyNosubcutaneousemphysemaIntercostalspacewasneithernarrowednorwidenedNotendernessThorax:SymmetricbilaterallyNodeformitiesBreast:SymmetricbilaterallyNeithernipplesnorskinwereretractedElasticitywasfineLungs:RespiratorymovementwasbilaterallysymmetricwiththefrequencyofminThoracicexpansionandtactilefremitusweresymmetricbilaterallyNopleuralfrictionfremitusResonancewasheardduringpercussionNoabnormalbreathsoundwasheardNowheezesNoralesHeart:NobulgeandnoabnormalimpulseorthrillsinprecordialareaThepointofmaximumimpulsewasinthleftintercostalspaceinsideofthemidclavicularlineandnotdiffuseNopericardialfrictionsoundBorderoftheheartwasnormalHeartsoundswerestrongandnosplittingRateminCardiacrhythmwasregularNopathologicalmurmursAbdomen:FlatandsoftNobulgeordepressionNoabdominalwallvaricosisGastralintestinaltypeorperistalseswerenotseenTherewasnottendernessandreboundtendernessonabdomenorrenalregionLiverwasnotreachedSpleenwasnotenlargedNomassesFluidthrillnegativeShiftingdullnessnegativeBorhorygmusminNovascularmurmursExtremities:NoarticularswellingFreemovementsofalllimbsNeuralsystem:PhysiologicalreflexeswereexistentwithoutanypathologicalonesGenitourinarysystem:NotexamedRectum:notexanedInvestigationNoProfessionalExaminationThereareaabout**cmmassinouterupfieldofherrightbreastItishardbutnotendnessItcanbemovedanditssurfaceissmoothTheskinofherbreastisnormalCorrespondingsuperficiallymphnodesdon’tenlargeHistorysummaryPatientwasateacher,female,yearsoldRightbreastmassfoundformorethanhalfamonthNospecialpasthistoryPhysicalexaminationshowednoabnormityinlung,heartandabdomanInformationaboutherbreastcanbeseenaboveShortingofinvestigationinformationImpression:Breastcancer(right)Signature:HeLin()

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