英文病例模版.doc

Name:Zhang jiuyuan Medical?Number:749939 PAGE PAGE 4 Medical?Records?for?Admisson Name:Zhang Jiuyuan Occupation:?Others Age:?Seventy Three Sex:?Female Race:?Han Date?of?admission:?Aug?6th,?2001Native place:?Chongqing Date?of?record:?11Am,?Aug?6th,?2001Marital?status:?Married Complainer?of?history:?The Patient (Reliable) Address:?Long toujin yuan,Huang nibang,Yubei,Chongqing.?Tel:Chief?complaint:?One lump prolapse out of vagina for 4+ months. Present?illness:? Before 4+ months ago,the patient find that a lump prolapse out of the vagina after elbow grease or standing for a long time, gradual become worse,even as large as a pigeon egg,but no tenderness.I can come back after rest in bed,and no frequency and rugency of micturition,painful micturition or hematuresis.No hypogastrium and lumbosacral portion distending pain,no anus drop distension or astriction , leucorrhea is normal.But do nothing for that.The patient have gone to the third people’s hospital of Chongqing to inspect(the dital was not clear),and she has been adviced to do a surgical,but not obey.One day before,the patient cames to our hospital hopes to make a diagnosis and give treatment. Gynecologial examination of outpatient service :The former wall of the vagina is projecture out of the ostium vagina; cervix uteri :Low-grade debaucjed,fall to the ostium vagina;Uterus body: meso-position,Slightly smaller. So?the?patient?was? accepted?because of?“Descensus uteri Ⅰ degree,and the former wall of the vagina projecture”. Since?the?disease?coming?on,?the?patient’s spirit and appetite is normal,the stool and urinate were natural.? Past?history：The?patient?is?healthy?before.The history of vaccinoprophylaxis was not clear,No?history?of hepatitis, tuberculosis or other?infective?diseases.? No?allergy?history?of?food?and?drugs.?Never?undergoing?any?operation or transfusion. System review Respiratory?system:?No?hist