胆囊结石病历模板（Gallbladder stone medical record template）.docVIP

胆囊结石病历模板（Gallbladder stone medical record template） Repeated complaints: right upper abdominal dull pain during the first half of the year History: the patient reported before admission due to half a year ago was no apparent cause right upper abdominal severe angina, paroxysmal aggravation, radiation to the right back, with fever and vomiting had no fear of cold, abdominal distension and diarrhea, dysuria, urinary frequency urgency, was attending the outpatient b-tip check 1. common bile duct and left hepatic duct the left hepatic duct, common bile duct calculi 2. and left intrahepatic bile duct dilatation 3. cholecystitis, gallbladder stone 4. sediment samples of liver parenchyma were not diagnosed as cholelithiasis, cholecystitis, with anti-inflammatory and analgesic infusion therapy can relieve the abdominal pain (specific and unspecified). Since then, after every tired, eating oily food, these symptoms occur repeatedly, both in our hospital outpatient or county hospital clinic, anti-inflammatory and other symptomatic treatment can be improved. Over the past 2 months compared with the previous sense of right upper quadrant pain frequently accompanied by dizziness, body pain and fatigue, no eye skin yellow, yellow, yellow urine, frequent urination, dysuria, acute abdominal distension and diarrhea, nausea and vomiting, fear of cold symptoms such as fever, also had a lot of patients outside the hospital outpatient service to private infusion and oral administration of Western Medicine (also specific unknown) without obvious symptoms improved, the thorough treatment, outpatient department intends to cholelithiasis, chronic cholecystitis admitted . Calvin: flank pain, leisurely endlessly, dry mouth and throat, Fanre hearts, dizzy, two tone. Past history: deny the history of infectious diseases such as hepatitis, tuberculosis, typhoid fever, no trauma surgery and blood transfusion history, deny the history of drug food allergy, and the history of vaccination is unknown