妇产科英文模板

CASEMedicalNumber:756943GeneralinformationName:YueJun-rongAge:Forty-twoyearsoldSex:FemaleRace:HanOccupation:UnemploymentNationality:ChinaMaritalstatus:MarriedAddress:XiaochangcountyofXiaogancityinHubei.Tel:[phone]Dateofadmission:Feb.27th,2003Dateofrecord:3pm,Feb.27th,2003Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Thepatientwasfound“myomaofuterus”overtwoyearsagoandmenometrorrhagiafor5months.Presentillness:In1999,thepatientwasfound“myomaofuterus”inaphysicalexamination.Butshehadnothinguncomfortableandhercatameniawasnormal.SheusedsomeChinesetraditionalmedicine.About5monthsago,shefoundthecycleofhercatameniawasshortenfrom30daysto20daysandtheperiodlastedfrom2daysto4days.Shefeltnopainandthequantitywasnormal.Shewasacceptedinourhospitalandherdiagnosiswas“subserousmyomaofuterus”.Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,too.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninHubeionJuly16th,1956andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas14.Lasting2dayseverytimesanditscycleisabout30days.Obstetricalhistory:Pregnacy3times,oncenatureproduction,inducedabortiontwice.Contraceptivehistory:Notclear.Familyhistory:Hisparentsarebothalive.PhysicalexaminationT36.8℃,P80/min,R20/min,BP120/80mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.HeadCranium:Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Oralmucousmembranewassmooth,andofnoulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotenlarged.Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.Thorax:Symmetricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof20/min.Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate80/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Therewasnottendernessandreboundtendernessonabdomenorrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.Genitourinarysystem:Notexamed.Rectum:notexanedInvestigationBlood-Rt:Hb127g/lRBC3.93T/lWBC3.9G/lUrine-Rt:SG1.070pH6.0B-ultrasound:1.subserousmyomaofuterus2.positionofloopisnormalHepaticfunction:NormalPT&APTT:NormalProfessionalExaminationPudendum:MarriedtypeVagina:unobstructed,secretionisexcessive,whiteandropy.Osofcervix:Nobleeding,slightanabrosis.Bodyofuterus:Biglikeafistofman,hardanditssurfaceissmooth.Others:NormalHistorysummary1.Patientwasfemale,45yearsold2.Thepatientwasfound“myomaofuterus”overtwoyearagoandmenometrorrhagiafor5months..3.Nospecialpasthistory.4.Physicalexaminationshowednoabnormityinlung,heartandabdoman.Professionalexaminationcanbeenseenabove.5.investigationinformation:seeaboveImpression:subserousmyomaofuterusSignature:HeLin(95-10033)来源：杨帆|分享(7)|浏览(49)