耳鼻喉科英文大病例.docx

学号：XXX 姓名：XXX学院：XXX 专业：XXXXX Hospital of XX University Medical Records for Admisson of Otolaryngology-Head and Neck SurgeryDepartment: Otolaryngology-Head and Neck Surgery Ward: Bed Number: XXMedical Number: XXGeneral information Name:XX Sex:Male Age:Thirty-eight Birthplace:XX Identification Card:XX Occupation: Unknown Race: Han Marital status: Married Patient’s workplace and telephone number:unknown Patient’s address(registered permanent residence) and telephone number:XXXXTelephone: XXContact person’s address and telephone number: XXXxTelephone: XXContact person(Relation with the patient): XX(Himself)Date of admission: Apr 12th, 2015Complainer of history(Name): XXRelation with the patient:HimselfChief Complaint: Repeated episodes of rhinobyon and pus snot for five years.Present illness: The patient began to appear bilateral rhinobyon without any inducement more than five years ago.His rhinobyon was intermittent with the left side more serious.During the rhinobyon he had thick pus snot with its green yellow color and its relatively much amount.He had sensation of head fullness and felt an obvious decrease in his sensation odour.He had no rhinocnesmus,sneeze,diplopia,fever,nausea and vomiting,visual rotation,ocular motility disorders,cough,expectoration,pharyngalgia,dysphagia,dyspnea,palpitation,chest distress ,limb and joint movement disorder and other unpleasant symptoms.In other hospital computed tomography of the head showed nasosinusitis and gave no treatment.Now the patient needed surgical treatment and came to outpatient clinic of our hospital for further treatment.The patient was admitted in our department with a diagnosis of chronic inflammation of nose,paranasal sinus and nasal polyp through our outpatient clinic.The patient’s mental state and diet was relatively fine since he became ill.He slept passably well.His physical strength and weight was normal.His defecation was as usual.Past historyHis normal physical condition:Good 1.Good 2.Gene