妇科病例模版(国外英文资料).doc

妇科病例模版 Admission date: October 26, 2008, 10:15 Record date: November 27, 2008, at 11:14 PM Name: gender: age of woman: 34-year-old history: the woman herself Marriage: married people: nationality of the han nationality: Occupation: other units: telephone: Id number: Medical card number: Address: History of disease Main action: the 39th week, the discovery of the horizontal position in February Present history: the regular period of the menstrual cycle, the last time period is December 26, 2007, the due date is October 3rd, 2008. After more than 40 days, a mild nausea, vomiting, and other early pregnancy reactions occurred. We tested positive for the pregnancy test in our clinic, and B was diagnosed early with pregnancy. Early pregnancy denied having a history of cold and fever, and denied any history of toxicology, medicine and radioactive exposure. Gestational 20 weeks is conscious of fetal life. The abdomen is rising. Pregnancy in our tent card and regular prenatal, at 21 + 2 weeks ultrasound tip is equivalent to 20 + 5 weeks, ultrasound at 29 + 1 weeks is equivalent to 28 + 4 weeks, fetal cardiac structure and blood flow to did not see abnormalities. Progesterone 31 + 1 was found to be horizontal, no special treatment, 34 + 4 weeks in the buttock and the left side, not in the abnormal obstetric condition. During pregnancy, there is no abdominal pain, vaginal bleeding, headache, dizziness, blurred vision, no palpitations, no chest pain. Today, I came to my clinic and found it was horizontal, without vaginal water, bleeding and abdominal pain and bloating. The revenue service is pending. Past medical history: always healthy, denied hepatitis, tuberculosis infection history, deny that have diabetes, nephritis, high blood pressure, heart, blood, etc., has a history of major surgery and trauma history, vaccination is unknown, deny that history of drug allergy. The history of transfusion was denied. Personal history: born in the same place, graduated from junior high