传染科英文病历(共5页).doc

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1、精选优质文档-倾情为你奉上 Medical Records for Admisson Medical Number: General information专心-专注-专业Name: Chen Dong yinAge: Forty-fourSex: FemaleRace: HanNationality: ChinaAddress: NO.11, Macao Road, Whhan, Hubei. Tel: Occupation: PeasantMarital status: MarriedDate of admission: July 6th, 2002Date of record: 3pm,

2、 July 6th, 2002Complainer of history: the patient herselfReliability: ReliableChief complaint: Intertia and Dyspepsia for about decades days.Present illness: The patient felt dyspepsia, intertia, nausea and vomiting after her taking some traditional Chinese medicine orally for her headache about ten

3、 days ago. She didnt get a fever. The color of her urine is normal. The physical examination show no tenderness or reboundtenderness. The patient was examined at another hospital, the results show “HBV(+), the function of the liver is abnormal. So the patient came to our hospital and was accepted as

4、 “chronic hepatitis B”. Since the disease coming on, the patients mind and appetite is not as good as normal. Her sleeping, stool and urine are normal but her physical strength is a bit decline. Past history The patient is healthy before. No history of hepatitis. No allergy history of food and drugs

5、. Past history Operative history: Deligation of ovidut at 1985. Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali

6、mentary 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 h

7、istory of headache or dizziness.Personal history He was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs.Menstrual history: The first time when she was 14. Lasting 4 days every times and its cycle is about 28 days.

8、The latest time was at march,1999.Obstetrical history: Pregnacy 2 times, both nature production.Contraceptive history: Amenorrhea already.Family history: His parents are both alive.Physical examination T 36.5, P 63/min, R 16/min, BP 105/60mmHg. She is well developed and moderately nourished. Active

9、position. His consciousness was clear. His face and 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 found enlarged.Head Cranium: Hair was black and white, well distributed. No deformities

10、. 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 na

11、res 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 pupi

12、llary reactions to light were existent. Mouth: Oral mucous membrane was smooth, and there were not ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.Chest Che

13、stwall: 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. Lungs: Respiratory movement was bilaterally symmetric with the frequency of 16/min. thor

14、acic 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 5t

15、h 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 63/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No ab

16、dominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness or rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs.Extremities:

17、 No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exaned.InvestigationExamination of the hepatitis B: HBsAg(+), HBeAb(+), HBcAb(+);Function of the liver: STB: 27mol/L, ALT

18、: 352U/L .History summary1. Patient was female, 44 years old.2. Intertia and Dyspepsia for about decade days.3. No special past history.4. Physical examination: T 37.5, P 63/min, R 16/min, BP 105/60mmHg Spider angioma was not seen. No pitting edema. No abdominal wall varicosis. Gastralintestinal typ

19、e or peristalses were not seen. There was not tenderness or rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.5. investigation information: See above. Impression: 1.chronic hepatitis B Moderate. 2. Drug-induced hepatitis. Signature: Tang xin (97-10037)