口腔科英文病历.docxVIP

口腔科英文病历 Oral and Maxillofacial Surgery Complete Medical History (Zhang te) General informationName: Tao liliAge: Forty eightSex: Female General information Name: Tao lili Age: Forty eight Sex: Female Race: Han Occupation: worker Nationality: China Marital status: Married AddressNO.138,mawangdui Rvenue,changsha, Hunan. Tel:Date of admissionJun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself Reliability: Reliable Chief complaint: lower incisors gingivae mass found for more than 3 month ? Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae ? After touching it, she found a mass tendness, She did not get fever ‘dizziness, vertigo andeadache? the patient didn t pay attention it. Then the mass becamemore and more bigger, sothe patient she came to our hospital and asked for an operation ? Since onset, her appetite was good, and both her spiritednessand 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 acromegal y. 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 about 30 days ? Obstetrical history