急性阑尾炎出院录(国外英文资料).docVIP

急性阑尾炎入院录(国外英文资料) Yang zi center health hospital Hospital records The name Place of birth gender national age Date of admission marriage Record the date professional The history state, Work units address Main action: the transfer of the right lower right abdomen pain with fever, nausea and vomiting 1 day. Hpi: due to no obvious cause yesterday evening suddenly appeared and upper abdomen and periumbilical pain, persistent, the degree of acute, with nausea, vomiting, not projectile vomiting, vomiting, gastric contents in a local clinic treatment is invalid, the specific drug use is unknown, abdominal pain this morning shift and fixed in the lower right abdomen, and moderate fever, then come to our hospital. Since the patient onset, the mental condition is poor, the sleep is good, the appetite is decreased, the meaning is much but the solution is not clear, the urine is no apparent abnormality, the weight does not increase significantly. Past medical history: the patient health in the past, no history of infection such as hepatitis, tuberculosis, vaccination history is unknown, there is no history of trauma surgery, no blood transfusion history, no history of food and drug allergy, no other major disease history, there is no history of play. Personal history: local long-term residence local birth, no special living habits, no alcohol, tobacco, drugs and other habits, no pollution, no contact industrial poison, dust, radioactive substances, there is no history of play. Marriage history: the first stage is 13 years old, period 4-6 days, menstruation period 26-28 days, the last period of the period of September 21, 2012, menstruation medium, without pain. Married, married age, spouse healthy, have children. Family history: parents, brothers, sister health, have no disease similar to the patient, no family genetic disposition disease. Block check Temperature: ℃, the pulse of The Times/min, breathing: times/min, the blood pressure: / mmHg, Kg weight The mind is clear, the a