英语 病例 模板.docx

英语病例模板

英语病例模板

英语病例模板

CAＳＥ

ＭeｄicａlNuｍbｅr:68２７86

Generａlｉnfｏrｍａtｉon

Nａme:WangRｕnzhｅn

Ａge:Foｒｔythrｅe

Ｓｅx:Femaｌe

Race:Ｈan

Occupaｔion:Teachｅr

Natｉoｎａlｉｔy:China

Mａrｉtａｌｓtatus:Married

Address:NO、３8,ＨangｋｏnｇRoad,JiefaｎgＲvenｕe,Hankｏu,

Daｔeｏfaｄmiｓｓion:Ｊａn１1sｔ,20０1

Ｄａｔeofrｅcord:11Am,Jan11st,2001

pｌaiｎerofhisｔoｒｙ:thepatｉenｔheｒself

Ｒeliabiliｔy:Reliable

Chiefplaint:Rightｂreａstmassfoundfoｒmoｒethanhaｌfaｍontｈ、

Presenｔillｎess:Halｆamonthａgo,thｅｐatieｎtsuddeｎlyｆeｌｔpaininhｅｒｒiｇhtchｅsｔwhensｈeputupherhａnd、Afterｔｏuchingｉt,shefoｕnｄamasｓinｈerｒｉghｔbreast,bｕｔnoteｎdnｅss,aｎｄthｅpaｔiｅｎtdｉdn’ｔpａyaｔtｅｎtiｏｎiｔ、Ｔhenthｅpainbecａmemoreandｍoreserious,sothepatieｎtweｎtｔotumourhｏspitalanｄｒeceivｅdapaｔｈoloｇycｅntｅsis、Ｈerdｉagnosiswasbｒeaｓtcancer、Theｎshecametoourhｏspｉtalanｄａｓｋedｆoranｏpｅraｔion、

Sinｃeonｓeｔ,ｈeｒａppetｉｔｅwａsgood,andbothｈerｓpirｉtedneｓｓaｎdphysicalenerｇyarenormａl、Dｅfecationandurｉnaｔiｏnarｅnormａl,too、

Pasｔhiｓｔory

Operａtiｖehistorｙ:Ｎeverundｅrgoiｎｇanyopeｒａtiｏn、

Ｉnfｅctiｏushistory:Noｈistoryoｆsevereｉnfectioｕｓdisease、

Alｌｅrgichisｔory:Sheｗasnotａllergiｃtoｐｅniciｌliｎorsulfａmide、

Respｉrａtorysysｔem:Nｏhistｏryｏfreｓpiraｔorydiseａsｅ、

Ｃirｃulａｔｏrysyｓｔem:Nohistoryofｐｒecｏrdｉalpaｉn、

Alimentarysysteｍ:Noｈistｏryofｒegｕrgitatｉon、

Genitｏuriｎaｒｙsｙstｅm:Ｎohｉstｏｒyoｆgeniｔouｒinaryｄｉseasｅ、

Ｈｅmａｔｏpoｉetiｃsyｓｔem:Ｎohistoｒyofanｅｍiａａｎdｍucocｕtaneousbleedinｇ、

Eｎdｏcrｉｎeｓystｅm:Ｎoacrｏmegａlｙ、Noeｘcesｓivesweats、

Kinｅtiｃｓｙstem:Nohiｓｔoryofconfineｍeｎｔｏflimｂs、

Neｕraｌsysｔｅm:Nohistoryofheadacｈｅoｒdizziness、

Ｐeｒsonａlhisｔory

SｈｅｗasbｏrninＷuhanｏｎNｏv19th,1９５7aｎdalｍostalｗaｙslivｅdinWuｈan、Shｅgraｄuatedfrｏmseniｏrｈighschool、Herlivingｃonditｉｏｎsｗerｅgｏod、Nｏbadpeｒsonaｌhabiｔsａndcｕstｏmｓ、

Mｅｎｓｔruaｌhistoｒy:Thefirｓttimeｗhｅnｓhｅｗａs14、Laｓtinｇ3to４daｙｓｅveｒytimｅｓａｎditｓcyｃleisaｂｏuｔ3０ｄays、

Obstetｒｉc