妇产科英文病历.doc

Inpatient History Name: Yali Zhou Sex: Female Age: 38year Ward: No.8 Bed: No.816 Marital status: Married Birthplace: Shanghai Nationality: Han Provider: Patient, reliable. Record date: 2005-12-13 G O History: GW: 30+5weeks, G2P0, LMP: 2005-5-10; EDC: 2006-2-17 Chief Complaint: G2P0, GW: 30+5weeks. This patient presents hypertension for 3 months, and systemic edema for 2 weeks. History of Present illness: The patient had regular menses previously. LMP: 2005-5-10; EDC: 2006-2-17. Uric HcG test was positive after 40 days of amenorrhea. Fetal movements were felt in 4 months’ gestation. In 12+2weeks’ gestation, the patient’s blood pressure was found 160/90 mmHg when she completed her first ante-partum examination in Hospital of Women and Children’s Health in Huangpu District. There was no symptoms at that time, and she didn’t take any treatment. Half a month ago, she presented edema on both the lower extremities, which expanded to the whole body gradually. She came to our hospital on Dec, 5th and took her sencond ante-partum examination. The bp was 200/160mmHg, and uric protein(++) on dipstick test. She has occasional headaches, but no epigastric pain, no visual disturbances, no oliguria, no nausea or vomiting, no thoracic pain. She was admitted on 2005-12-6. After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation. Past history: Patient denies history of hepatitis and tuberculosis. No history of allergies. Vaccinated regularly. Past medical history is unremarkable. Surgical history denied. No history of severe trauma and transfusion. Review of systems: Respiratory system: No history of chronic cough or breathlessness. No hemoptysis or dyspnea. Cardiovascular system: No precordial pain. No palpation. No syncope. For details see present history. Gastroentestinal system: No history of chronic abdomin