英语病例模板.docxVIP

精品文档

精品文档

.

.

Generalinformation

CASE

MedicalNumber:682786

Name:WangRunzhen Rvenue, Hankou, Hubei.

Age:Fortythree Tel:Sex:Female Date of admission: Jan

Race:Han 11st,2001

Occupation:Teacher Date of record: 11Am,

Nationality:China Jan11st,2001

Maritalstatus:Married Complainer of history:

Address: NO.38, thepatientherself

Hangkong Road, Jiefang Reliability:Reliable

Chiefcomplaint:Rightbreastmassfoundformorethanhalfamonth.

Presentillness:Halfamonthago,thepatientsuddenlyfelt

paininherrightchestwhensheputupherhand.Aftertouchingit,shefoundamassinherrightbreast,butnotendness, and the patient didn’tpay attention it. Then thepainbecamemoreandmoreserious,sothepatientwenttotumour hospital and received a pathology centesis. Herdiagnosiswasbreastcancer.Thenshecametoourhospitalandaskedforanoperation.

Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,too.

Pasthistory

Operativehistory:Neverundergoinganyoperation.

Infectious history: No history of severe infectious

disease.

Allergic history: She was not allergicto penicillin orsulfamide.

Respiratorysystem:Nohistoryofrespiratorydisease.

Circulatorysystem:Nohistoryofprecordialpain.

Alimentarysystem:Nohistoryofregurgitation.Genitourinary system: No history of genitourinarydisease.

Hematopoietic system: No history of anemia andmucocutaneousbleeding.

Endocrinesystem:Noacromegaly.Noexcessivesweats.

Kineticsystem:Nohistoryofconfinementoflimbs.

Neuralsystem:Nohistoryofheadacheordizziness.

Personalhistory

ShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.

Menstrualhistory:Thefirsttimewhenshewas14.Lasting3to4dayseverytimesanditscycleisabout30days.

Obstetricalh