传染科英文病历.docxVIP

Medical Records for Admisson General information Name: Chen Dong yin Age: Forty-four Sex: Female Race: Han Nationality: China Address: NO.11, Macao Road, Whhan, Hubei. Tel: 8260504 Medical Number: 733735 Occupation: Peasant Marital status: Married Date of admission: July 6th, 2002 Date of record: 3pm, July 6th, 2002 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Intertia and Dyspepsia for about decades days. Present illness: The patient felt dyspepsia, intertia, nausea and vomiting after her taking some traditional Chinese medicine orally for her headache about ten days ago. She didn’t get a fever. The color of her urine is normal. The physical examination show no tenderness or reboundtenderness. The patient was examined at another hospital, the results show “HBV(+), the function of the liver is abnormal. So the patient came to our hospital and was accepted as “chronic hepatitis B”. Since the disease coming on, the patient’s mind and appetite is not as good as normal. Her sleeping, stool and urine are normal but her physical strength is a bit decline. Past history The patient is healthy before. No history of hepatitis. No allergy history of food and drugs. Past history Operative history: Deligation of ovidut at 1985. Infectious history: No history of severe infectious disease. Allergic history: He 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 He was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs