耳鼻喉科英文大病例.docx

学号：XXX 姓名：XXX学院：XXX 专业：XXXXX Hospital of XX University Medical Records for Admisson of Otolaryngology-Head and Neck SurgeryDepartment: Otolaryngology-Head and Neck Surgery Ward: Bed Number: XXMedical Number: XXGeneral information Name:XX Sex:Male Age:Thirty-eight Birthplace:XX Identification Card:XX Occupation: Unknown Race: Han Marital status: Married Patients workplace and telephone number:unknown Patients address(registered permanent residence) and telephone number:XXXXTelephone: XXContact persons address and telephone number: XXXxTelephone: XXContact person(Relation with the patient): XX(Himself)Date of admission: Apr 12th, 2015 Complainer of history(Name): XXRelation with the patient:HimselfChief Complaint: Repeated episodes of rhinobyon and pus snot for five years.Present illness: The patient began to appear bilateral rhinobyon without any inducement more than five years ago.His rhinobyon was intermittent with the left side more serious.During the rhinobyon he had thick pus snot with its green yellow color and its relatively much amount.He had sensation of head fullness and felt an obvious decrease in his sensation odour.He had no rhinocnesmus,sneeze,diplopia,fever,nausea and vomiting,visual rotation,ocular motility disorders,cough,expectoration,pharyngalgia,dysphagia,dyspnea,palpitation,chest distress ,limb and joint movement disorder and other unpleasant symptoms.In other hospital computed tomography of the head showed nasosinusitis and gave no treatment.Now the patient needed surgical treatment and came to outpatient clinic of our hospital for further treatment.The patient was admitted in our department with a diagnosis of chronic inflammation of nose,paranasal sinus and nasal polyp through our outpatient clinic.The patients mental state and diet was relatively fine since he became ill.He slept passably well.His physical strength and weight was normal.His defecation was as usual.Past historyHis normal physical condition:Good 1.Good 2.General 3.Relatively BadHistory of diseases(Review of systems:if there were symptoms,please wrote the onset time and current situation of the diseases in the following blanks.)Symptoms of Respiratory system: doesn t exsit 1.exsit 2.doesnt exsit Symptoms of Circulatory system:doesnt exsit 1.exsit 2.doesnt exsit Symptoms of Alimentary system: doesn t exsit 1.exsit 2.doesnt exsit Symptoms of Genitourinary system: doesn t exsit 1.exsit 2.doesnt exsit Symptoms of Hematopoietic system: doesn t exsit 1.exsit 2.doesnt exsit Symptoms of Endocrine system: doesn t exsit 1.exsit 2.doesnt exsit Symptoms of Neural system and psychiatric symptoms:doesn t exsit 1.exsit 2.doesnt exsit Symptoms of Kinetic system: doesn t exsit 1.exsit 2.doesnt exsit History of contagious disease: doesn t exsit 1.exsit 2.doesnt exsit Others: History of prophylactic inoculation: unknown 1.exsit 2.doesnt exsitVaccines of prophylactic inoculation:Operative and trauma history Operative history: exist Name and time of the surgery: surgery of appendicitis was performed in 1994 and rhinopolyp was performed in2004.The exact process was unknown.Trauma history:doesnt exsit Time and process of trauma:Transfusion History Transfusion History:doesnt exsit 1.exsit 2.doesnt exsitAllergic history of Drugs and food: Allergic history of Drugs and food: doesnt exsit 1.exsit 2.doesnt exsit 3.unknownPersonal history Place of residence:Wuhan Residence in areas of endemic diseases:doesnt exsitSmoking history:exsit 1. exsit 2.doesnt exsit approximately 20 cigarettes per day,lasting 20 yearsSmoking cessation: doesnt exsit 1.exsit 2.doesnt exsitDrinking history:doesnt exsit 1.exsit 2.doesnt exsitContact history of narcotics: doesnt exsit Visit Prostitutes: doesnt exsit 1.exsit 2.doesnt exsit 3.unknownHistory of marriage and birth: gender:female Age of marriage:25 Gestation: 1 Time Parturition: 1 Time1.natural Parturition 1 Time 2.surgical Parturition Time 3.spontaneous Abortion Time 4.artificial Abortion Time5.premature Birth Time 6.stillbirth TimeHealth condition of spouse: fineFamily History(Paying attention to hereditary disease and infectious diseases related to the patients disease)Father: Dead 1.Healthy 2.Ill 3.DeadMother:Healthy 1.Healthy 2.Ill 3.DeadOthers:Above medical history has been admitted by the representor. Signature of the patient:XX Physical ExaminationVital Signs: Temperature:36.5 Pulse: 80 times per minute Regular() Irregular() Resperation: 20 times per minute Regular() Irregular() Blood pressure 135/85 millimeters of mercury General Condition: Development:Fine Nutrition:Fine Expression: Freely 1.Freely 2.Others Degree of cooperation when examining : Cooperative 1.Cooperative 2.UncooperativeBody Type: Orthotonic Type 1.Asthenic 2. Orthotonic 3.Sthenic Gait: Normal 1.Normal 2.Abnormal Body posture: active position 1.active position 2.positive position 3.compulsive positionConsciousness: clear 1.clear 2.somnolence 3.lethargy 4.light coma 5.middle coma 6.deep coma 7.delirious speechSkin and Mucosa Color and luster: Normal 1.Normal 2.Pale 3.Flush 4.cyanosis 5.jaundice 6.Chromatosis Type and distribution of rash: doesnt exsit Subcutaneous hemorrhage and distribution: doesnt exsit Position and distribution of edema: doesnt exsit Liver palms: doesnt exsit 1. doesnt exsit 2. exsit Spider angioma: doesnt exsit Position:Others:Lymphnodes: Swelling of superficial lymphnodes: doesnt exsit 1.doesnt exsit 2.exsit Description:Head: Distribution of hair: normal 1.normal 2.abnormal Descirption: Others:Eyes: exophthalmos: doesnt exsit eyelid: no edema conjunctiva:no hyperaemia sclera:no stained yellow cornea:no ulcerationPupil: equal circles and sizes 1.equal circles and sizes 2.unequal Left: 4 millimeters Right: 4 millimetersPupillary light reflex: normal 1.normal 2.slow 3.disappearingLeft/Right: Others:Ear: Secretion of external auditory canal: doesnt exsit 1.doesnt exsit 2.exsit Left: Right: Others:Tenderness in the mastoid area: doesnt exsit 1.doesnt exsit 2.exsit Hearing disorder: doesnt exsit 1.doesnt exsit 2.exsit Description:Nose: nares flaring: doesnt exsit 1.doesnt exsit 2.exsit Description: Secretion:doesnt exsit 1. doesnt exsit 2.exsit Secreta:Tenderness in paranasal sinus: doesnt exsit 1.doesnt exsit 2.exsit Postion:Oral cavity: lip:ruddy mucosa:no ulceration tongue:middle tonsils: not large pharynx:no congestion teeth:Neck: neck stiffness: doesnt exsit 1.doesnt exsit 2.exsit the distance between mandible and sternum: 0-finger-breadth measurementcarotid artery: normal pulse 1.normal pulse 2.increased pulse 3.decresed pulseHepatojugular reflux sign:negative 1.negative 2.positive Trachea:middle 1.middle 2.deviation left: right:Thyroid: normal 1.normal 2. enlarge Description:Vascular murmur 1.doesnt exsit 2.exsit DescriptionChest: thorax: symmetry 1.symmetry 2.barrel chest3.flat chest 4.pigeon breast 5.funnel chest(Left: Right: Precordium:)breast: normal 1.normal 2.abnormalpercussion pain of sternum: doesnt exsit 1.doesnt exsit 2.exsitlung visual examination: respiratory movement: normal 1.normal 2.abnormalpalpation: vocal fremitus: normal 1.normal 2.abnormalpleural friction sound: doesnt exsit 1.exsit 2.doesnt exsit left:right;subcutaneous crepitation: doesnt exsit 1.doesnt exsit 2.exsitpercussion: normal clear 1.normal clear 2. abnormal position:auscultation: breath sounds 1.normal 2.abnormal location:Heart: visual examination: apex beat:normal 1.normal 2.unseen3.enhanced 4.dispersedposition of apex beat:normal 1.normal 2.shfiting(the distance from the collarbone midline inner side: centimeters outer side: centimeters)palpation: apex beat: normal 1.normal 2.heaving apex impulseinward impulsefremitus: doesnt exsit 1.doesnt exsit 2.exsit location: period:percussion: range of relative cardiac dullness: normal 1.normal 2.reduced 3.disappeared 4.enlarged left: right:auscultation: heart rate: 80 times per minute rhythm of the heart:regular 1.regular 2.irregular description:heart sounds: normal 1.normal 2.abnormalmurmur: doesnt exsit 1.doesnt exsit 2.exsitlocation: period: character: magnitude: conduction:peripheral vessel signs: doesnt exsit (1. doesnt exsit 2.pistol shot sound of great vessels 3.Duroziezs murmurs 4.capillary pulsasation 5.gaseous pulse 6.alternating pulse 7.corrigans pulse 8.pulse deficit)Abdomen: visual examination: shape:normal 1.normal 2.distension 3.scaphoid abdomen 4. gastric type: doesnt exsit 1.doesnt exsit 2.exsit intestinal type: doesnt exsit 1.doesnt exsit 2.exsitabdominal wall varicosis: doesnt exsit 1.doesnt exsit 2.exsit(direction:)surgical scar: doesnt exsit 1.doesnt exsit 2.exsit description:palpation: abdominal palpation: whole abdomen soft 1. whole abdomen soft 2.tension of whole abdominal musclepart:tenderness: doesnt exsit 1.doesnt exsit 2.exsit part:rebound tenderness: exsit 1.doesnt exsit 2.exsit part:liver: no enlargement,touch no enlarged liver in right ribs.gallbladder: cant touch in right ribs murphy sign:negativespleen: touch no enlargement in left ribskidney: no percussion painabdominal mass:doesnt exsitothers:percussion: hepatic dullness: exsit 1.exsit 2.diminution 3.vanishingupper bounds of the liver: the fifth intercostal space of right midclavicular lineshifting dullness:negative 1.negative 2.positive ascites: zero degreeauscultation: bowel sounds: normal 1.normal 2.hyperfunction 3.weaken 4.vanishinggurgling: doesnt exsit 1.doesnt exsit 2.exsitvascular murmur: doesnt exsit 1.doesnt exsit 2.exsitAnorectum: unexamined 1.unexamined 2.normal 3.abnormalExternalia: unexamined 1.unexamined 2.normal 3.abnormalSpine: normal 1.normal 2.malformed 3.tendernessArms and Legs: normal 1.normal 2.red and swelling of joints 3.ankylosis 4.clubbing of fingers and toes 5.muscle atrophy part:Neural system:abdominal reflexes: normal knee jerk: normalpathological reflexes: Babinski sign:negative Oppenheim sign:negative Gordon sign:negative Chaddock sign:negativemeningeal irritation sign: stiffness of the neck:doesnt exsit 1.doesnt exsit 2.exsit the distance between mandible and breastbone: zero finger-breadth-measurementcoordination movement: finger-to-nose test:normal alternating movement: normal heel-to-knee-to-shin test:normal Romberg test:normalSpecialized examination: Ear:Auricle: no malformation and no redness and swelling Mastoid process: absence of tenderness External auditory canal: unobstructed Eardrum: no perforation Tuning fork examination: unexamined Audiometry: unexamined acoustic immitance: unexaminedNose: external nose: no malformation,bilateral symmetry,no collapse of the dorsal nasal nasal vestibule: no redness and swelling of skin,no eminence nasal cavity: Through nasal endoscope examination we could see chronic congestion of mucosa of bilateral nasal cavity,a little shift of nasal septum.Chronic congestion and a bit thickening of mucosa of bilateral inferior nasal concha could also be seen and its reaction to ephedrine was fair.We could see a large amount of neoplasms like white lichees in bilateral nasal cavity.Its surface was relatively smooth and we could see some mucous and purulent secretion attached to them.paranasal sinuses: no tendernessPharyngeal: oropharynx: no obvious congestion soft palate: move relatively flexibly uvula:be middle nasopharynx:cant be seen through nasal endoscopeLarynx:see no neoplasmsOthers:doesnt exsitImportant examination results in outpatient service and other hospitals(auxiliary examination):(including examination items,medical establishments,dates and results)Computed Tomography of XX Hospital on February 11th,2015 indicated nasosinusitis and soft tissue density shadows in nasal cavity.Inflammatory polyp might be considered.Summary:1. The patients name was XX.He was male and 38 years old.He was admitted in hospital because of repeated episodes of rhinobyon and pus snot for five years.2. Specialized examination: Through nasal endoscope examination we could see