急性阑尾炎首次病程记录(国外英文资料).docVIP

急性阑尾炎首次病程记录(国外英文资料)Yunnan province unified the medical recordsMedical record sheetName: Chiang kai-shek laboratory: external gynaecologic bed number: 29 bed hospital number: 9365First history of illnessThe 2014-02-28 12:00Patient: stability jiang zhi, female, 82 years old, because of metastatic lower abdominal pain with nausea, vomiting, eight hours on February 28, 2014 10:40: hospital, I on February 28, 2014, he to the ward to see patients, its history features below:First, the characteristic of the caseOlder women, patients with no incentives in abdominal pain, 8 hours ahead of the early performance for upper abdomen ache pain gradually increase after 4 hours and transferred to the right lower abdomen is fixed, the small of the back and the perineum radiation pain, clonic seizures, accompanied by nausea, vomiting, several times, vomit for gastric contents, total amount of about 200 ml, without any treatment, today because of abdominal pain do not ease to come to our hospital, outpatient admitted to abdominal pain in dispute. In the course of the disease in patients with no cough, sputum, no heart palpitations, shortness of breath, difficulty breathing, abdominal distention, diarrhea, urinary frequency, urgency, urine pain and hematuria, sick, poor sleep, poor appetite, urine normal.. He has denied the history of drug allergy and denies the history of transfusion. Hospital physical examination: the temperature is 36.5 ℃, pulse is 80 times/min, 19 times/min breathing, blood pressure is 110/70 MMHG. General condition is good, automatic position, whole body shallow lymph nodes do not reach swollen. Double lung breathing. Heart rhythm, no noise. Specialized subject: the abdominal flatness, not see the gastrointestinal type and the peristaltic wave, did not see the abdominal wall vein qu zhang, the right lower abdomen the point of the right lower abdomen the pressure of the pain positive, the anti-jumping pain positive, the non-muscular strain. Moffie was negative, the