腹痛3(国外英文资料).docVIP

腹痛3 The guangsha hospital in ordos city A summary of inpatient medical records is reviewed Outpatient number: 15411 The hospital number: 15126 Internal medicine name: bian yu mei gender: female national han age 63 years Unit address Admission date, 2008, 2008 The date of the operation The discharge date was hospitalized for six days on 01 September 2008 : the course of the disease and treatment of patients after admission by perfecting the relevant auxiliary check and give the pain, anti-inflammatory, rehydration symptomatic treatment, such as abdominal pain, nausea and vomiting, diet, sleep. Normally, discharged today. Discharge diagnosis: the cause of abdominal pain? Therapeutic effect: better Discharge doctors order: 1. Rest 2, discomfort follow-up Doctor: cui lijun Temperature 36.4 ℃, pulse is 90 / cent, 16 times/min breathing, blood pressure is 130/55 MMHG. The general condition develops normally, the nutrition is good, the expression is natural, the autonomic position, walks into the ward, the shen zhi is clear, the examination body cooperate. Skin color of skin mucous membrane is normal, without rash and subcutaneous hemorrhage, hair black distribution is even, have no liver palm and spider arachnoid. The skin mucous membrane temperature is normal, humidity is normal, do not see icteric. Lymph nodes under the chin, jaw, neck, collarbone, armpit, and right groin may be able to reach swollen lymph nodes. The head is normal, hair black is spread evenly, the head has no scar, no lump. Eye, eyelid edema, palpebral conjunctiva congestion, edema, sclera, no yellow dye, the transparency of the cornea, pupil big circle, such as around the pupil are 0.3 cm, light reflex, reflex regulation and the world. Ear: the hearing is good, there is no pus, the auricle and the mastoid have no tenderness. Nose: smooth, no bending of the nose, no movement of the nose, no tenderness in the sinus area, no runny nose, bleeding. Oral cavity: red lip, no cyanosis, the teeth are lined up