外科英文病例模板

CASE

Medical Number: 682786 General information

Name:Ding Zier

Age: Forty seven

Sex: Female

Race:Han

Occupation:farmer Nationality:China

Marital status: Married Address:jianli county，Jingzhou City,Hubei Province

Date of admission:April 17, 2013 Date of record: April 17, 2013 Complainer of history: the patient herself

Reliability: Reliable

Chief complaint: Intermittent low back pain for 10 years Present illness: Ten years ago, the patient suddenly felt pain in the lower back,with hematuria , but no urinary frequency, urgency, dysuria, fever and other symptoms.After the Left kidney stones removal surgery,Patients with low back pain relief.Five years ago, patients felt intermittent low back pain with urinary frequency, urgency again, no dysuria, hematuria, fever and other symptoms, the patient didn’t treat it.2013-02-24 reviewed the ultrasound found that "Left kidney stones" .For the sake of further treatment, then come to our hospital, outpatient revenue to "Left kidney stones" to our department.

Since the onset, the patients private prosecution spiritedness, appetite, sleep somewhat less, slightly more urination, defecation is normal, no significant changes in physical weight. Past history

Operative history:10 years ago,did kidney stones removal surgery.

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 Jianli County and almost always lived in Jianli county. She did not go to school. Her living conditions were in general. No bad personal habits and customs.

Menstrual history: The first time when she was 16. Lasting 5 to 6 days every times and its cycle is about 33 days.

Obstetrical history:Pregnacy 4 times, 4 nature production, no abortion.

Contraceptive history: Not clear.

Family history: Her parents are still alive.

Physical examination

T 36.3℃, P 72/min, R 18/min, BP 116/76mmHg. 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. Respiratory movement was bilaterally symmetric with the frequency of 18/min. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 72/min. Cardiac