2023年口腔科英文病历.docx

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1、2023年口腔科英文病历 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 Addre:NO.138,mawangdui Rvenue,changsha, Hunan. Tel: 84722500

2、Date of admiion: Jun 20st, 2023 Date of record: 11Am, Jun20st, 2023 Complainer of history: the patient herself Reliability: Reliable Chief complaint: lower incisors gingivae ma found for more than 3 month.Present illne: 3 month ago, the patient suddenly found a small ma on lower incisors gingivae.Af

3、ter touching it, she found a ma tendne, She did not get fever ,dizzine, vertigo and headache.the patient didnt pay attention it.Then the ma 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 spiritedne and

4、 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 resp

5、iratory 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 exceive sweats. Kin

6、etic system: No history of confinement of limbs. Neural system: No history of headache or dizzine.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.Menstru

7、al 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,

8、 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

9、.No deformities.No scars.No maes.No tenderne. Ear: Bilateral auricles were symmetric and of no maes.No discharges were found in external auditory canals.No tenderne in mastoid area.Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi.Septum nasi was in midline.No nar

10、es flaring.No tenderne 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 depreed.Movement was normal.Bilateral pupils were round and equal in size.Direct and indirect pupillary reaction

11、s to light were existent. Neck: Symmetric and of no deformities.No maes.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 tenderne. Thorax: Symmetric bilaterally.No deformiti

12、es. Breast: Symmetric bilaterally.Neither nipples nor skin were retracted.Elasticity was fine. Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min.Thoracic expansion and tactile fremitus were symmetric bilaterally.No pleural friction fremitus.Resonance was heard during

13、 percuion.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 w

14、as normal.Heart sounds were strong and no splitting.Rate 80/min.Cardiac rhythm was regular.No pathological murmurs.Abdomen: Flat and soft.No bulge or depreion.No abdominal wall varicosis.Gastralintestinal type or peristalses were not seen.There was not tenderne and rebound tenderne on abdomen or ren

15、al region.Liver was not reached.Spleen was not enlarged.No maes.Fluidthrill negative.Shifting dullne 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.Genitou

16、rinary system: Not examed.Rectum: not exaned Investigation No. Profeional Examination Oral mucous membrane was smooth, and of no ulcer or erosion.Tongue was in midline.Pharynx was not congestive.Tonsils were not enlarged.Patients with poor oral hygiene has much dental calculus .There are a about 2*2

17、*1.5cm ma on lower incisors(33-41) gingivae.It is tender but not bleed.It can not be moved and its surface is smooth.Corresponding superficial lymph nodes dont enlarge. Impreion: Epulis Signature: Zhang te Hospital course record for the first time 2023-6-20 8:50 一、Characteristics of cases： 1.Clinica

18、l presentation:Patient was a worker , female, 48 years old.2.lower incisors gingivae ma found for more than 3 month. 3.No special past history. 4.Physical examination showed no abnormity in lung, heart and abdoman.Information about her oral can be seen above. 5.Shorting of investigation information.

19、 6.Temperature is36.5, pulse 80, respirations 20, blood preure 90/60. 二、Examination to discu diagnostic basis：1.lower incisors gingivae ma found for more than 3 month。2.She did not get fever ,dizzine, vertigo and headache.There are a about 2*2*1.5cm ma on lower incisors(33-41) gingivae.It is tender

20、but not bleed.There are a about 2*2*1.5cm ma on lower incisors(33-41) gingivae.It is tender but not bleed. differential diagnosis：Gingival carcinoma：Except fast growth, it can appear local canker, pain, involving related to teeth.ADMITTING DIAGNOSIS:Epulis 三、Case claification：A 四、Treatment plan：1.To

21、 improve the routine inspection.2.Whole mouth clean governance.3.Optional operation. Xu yuguo Hospital records 2023-6-21 The patient was hospitalized on this morning.with suddenly found a small ma on lower incisors gingivae 3 month ago. transparent mild redne, lining color is normal, Patients usuall

22、y in good health.Blood, urine, dung routine has been sent, liver and kidney function checklist to fill in, check the doctors advice already open.Pathological biopsy for the diseased tiue has been sent. Xu yuguo 2023-6-23 This morning Pro.zhang visits, the diagnosis and treatment of put forward the f

23、ollowing opinions:Pathological biopsy result has shown Epulis.All investigation is normal.According to the clinical manifestations of it ,this disease The disease can be diagnosed with Epulis.Gum tumor resection Can be imposed immediately.Preoperative should be whole mouth clean governance.surgery w

24、ill be done at eight on tomorrow morning . Zhang te/ Xu yuguo 2023-6-24 Preoperative SUMMARY Patient was a worker , female, 48 years old.lower incisors gingivae ma found for more than 3 month.No special past history.Physical examination showed no abnormity in lung, heart and abdoman.Information abou

25、t her oral can be seen above.All investigation is normal.whole teeth have been cleaned.Surgical treatment plan: (1) pastoperative biopsy to determine the tumor nature; (2) Complete removal of the tumor and spread of the periodontal membrane, teeth and gums.(3) a mandibular defect should still depend

26、ing on the nature of the tumor and then make a decision whether to immediately bone graft, but should be ready to immediately bone graft.(4) preoperative for teeth cleaning and use of antibiotics. Xu yuguo 2023-6-25 8:15 Operation records Make Routine local anesthesia on the patient supine, disinfec

27、tion and shop towels according to Maxillofacial surgery routine.lump completely and spread of the periodontal membrane, and gums been removed with electricity knife.hydrogen peroxide and saline flush incision.Ma was sent to Pathological biopsy.The patient went back the ward safetyly at 9:30 , The su

28、rgery was over. Zhang te 2023-6-26 Pastoperative records T 36.5, P 80/min, R 23/min, BP 100/60mmHg.Patients feel the wound and teeth pain is severe, the wound near swollen gums, jaw was covered with a little fake.Continue to Analgesic, anti-inflammatory.Pay attention to maintain oral hygiene.Patient

29、s require to dischange tomorrow, he Would be approved to agree with. Zhang te DISCHARGE RECORD DATE OF ADMISSION: Jun 20st, 2023 DATE OF DISCHARGE: Jun 26st, 2023 Number of days in hospital:6 Days ADMITTING DIAGNOSIS: Epulis BRIEF HISTORY PATIENT name :Tao lili , AGE: 48 3 month ago, the patient sud

30、denly found a small ma on lower incisors gingivae.After touching it, she found a ma tendne, She did not get fever ,dizzine, vertigo and headache.the patient didnt pay attention it.Then the ma became more and more bigger. REVIEW OF SYSTEM She has had no headache, fever, chills, diarrhea, chest pain,

31、palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle edema. PAST MEDICAL HISTORY She has had no previous surgery, accidents or childhood illne. SOCIAL HISTORY: She has no history of exceive alcohol or tobacco use. FAMILY HISTORY She has no family history of cardiovascular, respirata

32、ry and gastrointestinal diseases. PHYSICAL EXAMINATION Temperature is36.5, pulse 80, respirations 20, blood preure 90/60.General: Plump girl in no apparent distre.HEENT: She has no scalp lesions.Her pupils are equally round and reactive to light and accommodation.Extraocular movements are intact.Scl

33、erae are anicteric.Oropharynx is clear.There is no thyromegaly.There is no cervical or supraclvicular lymphadenopathy.Cardiovascular: Regular rate and rhythm, normal S1, S2.Chest: Clear to auscultation bilateral.Abdomen: Bowel sounds present, no hepatosplenomagaly.Extremities: There is no cyanosis,

34、clubbing or edema.Neurologic: Cranial nerves II-XII are intact.Motor examination is 5/5 in the bilateral upper and lower extremities.Sensory, cerebellar and gait are normal. HOSPITAL COURSE The patient was admitted .The patient was resect the gums tumor and improved.The patient was discharged in sta

35、ble condition. DISCHARGE DIAGNOSIS Epulis DISCHANGE INSTRCTIONS: To pay attention to rest, strengthen nutrition, keep the anti-inflammatory for three days.To maintain oral hygiene.To review on a regular basis. PROGNOSIS Good.No medications needed after discharge.The patient is to follow up with Dr.xu in one week. Zhang te/ Xu yuguo 口腔科英文病历 口腔科病历的规范书写 经典口腔科门诊病历 口腔科常用英文术语 口腔科病历书写要求及 口腔科医生答疑口腔科问题 口腔科(牙科)常用英文词汇 口腔科简介 口腔科简介 口腔科材料