口腔科英文病历

Oral and Maxillofacial Surgery Complete Medical History

（Zhang te）

Medical Number: 182786 General information

Name:Tao lili

Age: Forty eight

Sex: Female

Race:Han

Occupation: worker Nationality:China

Marital status: Married Address:NO.138,mawangdui Rvenue,changsha, Hunan.

Tel: 84722500

Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself

Reliability: Reliable

Chief complaint: lower incisors gingivae mass found for more than 3 month.

Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae. After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache. th e patient didn’t pay attention it. Then the mass became more and more bigger, so the patient 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℃, 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