妇科英文病历
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Medical Number: 756943General 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:
Date of admission:
Feb.27th, 2003
Date of record:3pm, Feb.27th, 2003
Complainer of history:
the patient herself
Reliability:
Reliable
The patient was found“ myoma of uterus” overtwo years ago and menometrorrhagia for 5 months.
Present illness:
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.
Hematopoietic system:
No history of anemia and mucocutaneous bleeding.
Endocrine system:
No acromegaly. No excessive sweats.
No history of confinement of limbs.
Neural system:
No history of headache or dizziness.
Personal history
She was born in Hubei on July 16th,1956and 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
sting 2 days every times and its cycle is about 30 days.
Obstetrical history:
Pregnacy 3times,once nature production,induced abortion twice.
Contraceptive history:
Not clear.
Family history:
His parents are both alive.
Physical examination
T
36.8℃, P 80/min, R 20/min, BP
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.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: