口腔科英文病历.doc

Oral and Maxillofacial Surgery Complete Medical History （Zhang te） Medical Number: 182786 General information Name: Tao lili Age: Forty eight Sex: Female Race: Han Occupation: worker Nationality: China Marital status: Married Address:NO.138,mawangdui Rvenue,changsha, Hunan. Tel:Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself Reliability: Reliable Chief complaint: lower incisors HYPERLINK app:ds:gingivaegingivae mass found for more than 3 month. Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors HYPERLINK app:ds:gingivaegingivae. After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache. the patient didn’t pay attention it. Then the mass became more and more bigger, so the patient she came to our hospital and asked for an operation. Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness. Personal history She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs. Menstrual history: The first time when she was 14. Lasting 3 to 4