外科英文病例模板.doc

CASE Medical Number: General informationName: Ding ZierAge: Forty sevenSex: FemaleRace: HanOccupation:farmerNationality: ChinaMarital status: MarriedAddress:jianli county，Jingzhou City,Hubei Province Date of admission: April 17, 2013Date of record: April 17, 2013Complainer of history: the patient herselfReliability: ReliableChief complaint: Intermittent low back pain for 10 yearsPresent 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 didnt 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 rhythm was not regular. No pathological murmurs. Abdomen was flat and soft. No bulge or depression. No abdominal wall varices. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdominal. There was rebound tenderness on renal region. Liver and spleen was untouched. No masses. Shifting dullness is negative. No vascular murmurs. No edema. Physiological reflexes were existent without any pathological ones.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 bilaterally symmetric with the frequency of 18/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 76/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There were tenderness and rebound tenderness on renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. 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 exanedInvestigationFebruary 24, 2013 Jianli County People's Hospitalultrasound showed :multiple stones in the left kidney, liver calcification. Professional Examination The ureter walking area: normal Meatal: normalExternal vaginal orifice: normalClitoris: normal Anus: normalHistory summary1. Patient was a farmer, female, 47 years old.2. Intermittent low back pain for 10 years.3. No special past history but10 years ago,did kidney stones removal surgery.4. Physical examination showed that there were tenderness and rebound tenderness on renal region,no abnormity in lung, heart and abdominal.5. investigation information: February 24, 2013 Jianli County People's Hospitalultrasound showed :multiple stones in the left kidney, liver calcification.Impression: Left kidney stones Signature: Chen Zhiqiang