外科英文病历模板教学内容.doc

CASE Medical Number: 682786 General information Name: Wang Runzhen Age: Forty three Sex: Female Race: Han Occupation: Teacher Nationality: China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Date of admission: Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then 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 days every times and its cycle is