英文病例书写
Íâ?Æ??
CASE
Medical Number: 682786
General information
Name: Wang Runzhen
Age: Forty three
Sex: Female
Race: Han
Occupation: Teacher
Nationality: China
Marital status: Married
Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500 Date of admission: Jan 11st, 2001
Date of record: 11Am, Jan 11st, 2001
Complainer of history: the patient herself
Reliability: Reliable
Chief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn??t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation.
Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.
Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease. Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain.
Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary disease.
Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats.
Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.
Menstrual history: The first time when she was 14. Lasting 3 to 4 days every times and its cycle is about 30 days.
Obstetrical history: Pregnacy 3 times, once nature production, abortion twice. Contraceptive history: Not clear.
Family history: His parents have both died.
Physical examination
T 36.4?æ, P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged.
Head
Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.
Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.
Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.
Thorax: Symmetric bilaterally. No deformities.
Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine.
Lungs: Respiratory movement was bila
Medical Records for Admisson
Medical Number: 701721
General information
ÄÚ?Æ
Name: Liu Side
Age: Eighty
Sex: Male
Race: Han
Nationality: China
Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: Retired
Marital status: Married
Date of admission: Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001
Complainer of history: patient??s son and wife
Reliability: Reliable
Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
Present illness:
The patient felt upper bellyache about ten days ago. He didn??t pay attention to it and thought he had ate something wrong. At 6 o??clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of ??upper gastrointestine hemorrhage and exsanguine shock??. Since the disease coming on, the patient didn??t urinate. Past history
The patient is healthy before.
No history of infective diseases. No allergy history of food and drugs. Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain.
Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats.
Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient.
Obstetrical history: No
Contraceptive history: Not clear.
Family history: His parents have both deads.
Physical examination
T 36.5?æ, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.
Head
Cranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.
Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.
Thorax: Symmetric bilaterally. No deformities.
Breast: Symmetric bilaterally.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. t
???ù?Æ??
Medical Records for Admisson
Medical Number: 696235
General information
Name: Zhang Yi
Age: thirteen
Sex: Female
Race: Han
Nationality: China
Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723 Parents Name: father Zhang Hesheng
Mother Yang Chiulian
Date of admission: May 8th, 2001
Date of record: 11Am, May 8th, 2001
Complainer of history: patient??s mother
Reliability: Reliable
Chief complaint: Pharyngalgia and fever for four days.
Present illness:
The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children??s Hospital, there she received treatment of antibiotics, but her symptoms didn??t abate. So her parents took her to our hospital, she was admitted with a diagnosis of ??fever of unknown??
Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.
Past history
The patient is healthy before.
No history of ??measles?? or ??pertussis?? etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa. Personal history
1.Natal: First birth born, uneventfully and on full term with birth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding. 2.Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her intelligence was normal.
3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned from the breast at 14th month. 4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpox voccination).
Physical examination
T 39.5?æ, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Head
Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found
in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.
Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.
Thorax: Symmetric bilaterally. No deformities.
Breast: Symmetric bilaterally.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 30/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.
Heart: No bulge and no abnormal impulse or thrills in precordial ar
?????Æ??
CASE
Medical Number: 756943
General information
Name: Yue Jun-rong
Age: Forty- two years old
Sex: Female
Race: Han
Occupation: Unemployment
Nationality: China
Marital status: Married
Address: Xiaochang county of Xiaogan city in Hubei.
Tel: 4835963
Date of admission: Feb.27th, 2003
Date of record: 3pm, Feb.27th, 2003
Complainer of history: the patient herself
Reliability: Reliable
Chief complaint: The patient was found ??myoma of uterus?? over two years ago and menometrorrhagia for 5 months.
Present illness: In 1999, the patient was found ??myoma of uterus?? in a physical examination. But she had nothing uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was ??subserous myoma of uterus??.
Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.
Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease.
Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain.
Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary disease.
Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats.
Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
She was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.
Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.
Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.
Contraceptive history: Not clear.
Family history: His parents are both alive.
Physical examination
T 36.8?æ, P 80/min, R 20/min, BP 120/80mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged.
Head
Cranium: Hair was black and well distributed. No deformities. No scars. No masses.
No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.
Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.
Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.
Thorax: Symmetric bilaterally. No deformities.
Breast: Symmetric bilaterally. Neither nipples nor skin were retr
[תÌû]Ó?ÎÄ??ÀúÊéÐ???Àý??ÄÚ?Æ??0
Medical Records for Admisson
Medical Number: 701721
General information
Name: Liu Side
Age: Eighty
Sex: Male
Race: Han
Nationality: China
Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: Retired
Marital status: Married
Date of admission: Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001
Complainer of history: patient??s son and wife
Reliability: Reliable
Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
Present illness:
The patient felt upper bellyache about ten days ago. He didn??t pay attention to it and thought he had ate something wrong. At 6 o??clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of ??upper gastrointestine hemorrhage and exsanguine shock??.
Since the disease coming on, the patient didn??t urinate.
Past history
The patient is healthy before.
No history of infective diseases. No allergy history of food and drugs. Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease.
Allergic history: He was not allergic to penicillin or sulfamide.
Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain.
Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary disease.
Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats.
Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs.
Menstrual history: He is a male patient.
Obstetrical history: No
Contraceptive history: Not clear.
Family history: His parents have both deads.
Physical examination
T 36.5?æ, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.
Head
Cranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed.
Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.
Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.
Thorax: Symmetric bilaterally. No deformities.
Breast: Symmetric bilaterally.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.
Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.
Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs.
Extremities: No articular swelling. Free movements of all limbs.
Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed.
Rectum: not exaned
Investigation
Blood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L
History summary
1. Patient was male, 80 years old
2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
3. No special past history.
4. Physical examination: T 37.5?æ, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.
5. investigation information:
Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L
Impression: upper gastrointestine hemorrhage Exsanguine shock