妇科英文病历

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℃, 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.