各科英文病历集锦眼科英文病历

Name: Liu Side Age: forty Sex: Male Address: NO.35, Dandong Road, Jiefang Revenue, Hankou, Hubei. Occupation: officer Marital status: Married Date of record: 9Am, Sept 9th, 2002 Chief complaint: Red eyes with secretion increased for three days. Present illness: The patient found that his eyes turned red without obvious causes three days ago. The mucoid secretion in eyes increased consequently. He also felt pain in his eyes and photophobia presented. However, he did not receive any treatment, and these symptoms getting severe. Past history Denied hypertension and diabetes. No allergic history of drugs. Physical examination & Slit lamp microscope examination The eyelids are normal. Congestion in both conjunctivas. No papilla and follicle. The corneas are lucent and the aqueous humor is clear. FL (-), BUT>10s, Tyndall (-). The pupils are round in the diameter of 3mm. Reflection to light is sensitively. Ocular fundus Optic papilla has clear boundary. C/D 0.3*0.3, A/V 2:3. Impression Acute conjunctivitis Treatment 1. Talivid eye drops, ou qid 2. Rifampicin eye drops, ou qid 3. Tetracycline eye ointment, ou qn 4. Come back to see the doctor if something getting worse Signature: Huang Yao 黄 尧 97-10018