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首页 各科英文病历集锦耳鼻喉病历

各科英文病历集锦耳鼻喉病历.doc

各科英文病历集锦耳鼻喉病历

bcchen
2018-09-05 0人阅读 举报 0 0 暂无简介

简介:本文档为《各科英文病历集锦耳鼻喉病历doc》,可适用于医药卫生领域

CompleteMedicalHistoryMedicalNumber:Name:RenJianrongAge:yearsoldSex:FemaleRace:HanOccupation:JoblessNationality:ChinaMaritalstatus:SingleAddress:JiangxiacountyinWuhan,HubeiTEL:Dateofadmission:Septst,Dateofrecord:pm,Septst,Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:UncomfortablefeelingandexcretioninnoseforyearsPresentillness:ThepatienthasfeltuncomfortablefeelingandhadsomeexcretioninnosewithoutobviouscausesyearsagoTheexcretionwasclearShedidnotgetfever,dizziness,vertigoandheadacheShewenttolocalhospital,thediagnosiswas“Deviationofnasalseptum”Thedoctoradvisedhertooperation,however,shedidnothaveenoughmoneythenShereceivedsomemedicaltherapy(notdetailed)Askingforoperation,shecametotheoutpatientdepartmentofourhospitalthistime,andwasadmittedwiththediagnosisof“Deviationofnasalseptum”Duringthecourseoftheillness,herappetiteisgood,andbothherspiritandphysicalstrengtharenormalDefecationandurinationarenormalPasthistoryShedoesn’thaveallergichistorytopenicillinorsulfamideDeniedhypertension,diabetesectDiseasesPersonalhistory:ShewasborninWuhanonNovst,andalwayslivedatthereHerlivingconditionsisaverageShedoesn’thavebadhabitsMenstrualhistory:ThefirsttimewhenshewasLastingtodayseverytimesandthecycleisaboutdaysThelatesttimewasonSeptstObstetricalhistory:Pregnacytimes,artificialabortionfivetimesContraceptivehistory:NotclearFamilyhistory:HerparentsarebothaliveandhealthyPhysicalexaminationT℃,Pmin,Rmin,BPmmHgSheiswelldevelopedandmoderatelynourishedActivepositionTheskinisnotstainedyellowNocyanosisNopigmentationNoskineruptionSpiderangiomaisnotseenNopittingedemaSuperficiallymphnodesarenotenlargedHeadEarNoseMouth:SeeprofessionalexaminationEye:NoptosisNoentropionConjunctivaisnotcongestiveMovementisnormalBilateralpupilsareroundandequalinsizeDirectandindirectpupillaryreactionstolightareexistentNeck:NomassesThyroidisnotenlargedTracheaisinmidlineChestBreast:SymmetricbilaterallyNeithernipplesnorskinareretractedElasticityisfineLungs:RespiratorymovementisbilaterallysymmetricwiththefrequencyofminThoracicexpansionandtactilefremitusaresymmetricbilaterallyNopleuralfrictionfremitusResonanceisheardduringpercussionNoabnormalbreathsoundisheardNowheezesNoralesHeart:NobulgeandnoabnormalimpulseorthrillsinprecordialareaThepointofmaximumimpulseisinthleftintercostalspacecminsideofthemidclavicularlineandnotdiffuseNopericardialfrictionsoundBorderoftheheartisnormalHRminCardiacrhythmisregularNopathologicalmurmursAbdomen:FlatandsoftNobulgeordepressionNoabdominalwallvaricosisGastralintestinaltypeorperistalsesarenotseenThereisnottendernessandreboundtendernessonabdomenorrenalregionLiverisnotreachedSpleenisnotenlargedNomassesFluidthrillnegativeShiftingdullnessnegativeNovascularmurmursExtremities:FreemovementsofalllimbsNeuralsystem:PhysiologicalreflexesareexistentwithoutanypathologicalonesGenitourinarysystem:NotexamedRectum:NotexamedInvestigationAbsentProfessionalExaminationEar:BilateralauriclesaresymmetricandofnomassesNodischargesarefoundinexternalauditorycanalsNotendernessinmastoidareaAuditoryacuityisnormalNose:NormalappearanceThereissomecleardischargesinnasalcavitySeptumnasideviatestorightAridgeprominenttorightcouldbeseenNonaresflaringNotendernessinnasalsinusesPharynxandlarynx::Oralmucousmembraneissmooth,andofnoulcerorerosionTongueisinmidlinePharynxiscongestiveTonsilsareenlarged(I)HistorysummaryRenJianrong,female,yearsoldUncomfortablefeelingandexcretioninnoseforyearsNospecialpasthistoryPhysicalexamination:T℃,Pmin,Rmin,BPmmHgSuperficiallymphnodeswerenotfoundenlargedThelungwasnormalHRbpmwithregularrhythmNocardiacmurmursTheabdomentwereplainandsoftNotendernessorreboundtendernessLiverandspleenwasuntouchedNomassesShiftingdullnessnegativeInvestigationinformation:AbsentProfessionalExamination:SeeaboveImpression:DeviationofnasalseptumSwollentonsil(I)Signature:HuangYao黄尧PAGE

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各科英文病历集锦耳鼻喉病历

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