英文大病历（外科）.doc

Complete Medical History Name: Guo Ying Sex: female Profession: administer Age:31 yearsNative place: Tian Jin Address: south and west village of NanKai universityMarital state: married Nationality: Han Date of admission: February 13 2003 Date of history taking :February 13 2003Narrator: the patient Reliability of the history: reliable The History Chief Complaint: abdominal pain of right lower abdomen for 2days accompanying with fever and vomiting for 1 day.Present Illness:2 days ago, without any reason, the patient felt abdominal pain. At the beginning the site of pain was not so clear and the pain was not very severe. Without fever ,nausea or vomiting, diarrhea and so on. So the symptom did not cause any attention. But some hours later , the symptom developed to be more severe and the site was more clear mainly at the right lower abdomen then the patient went to the clinic nearby, and got some drugs for abdominal pain. After that the symptom improved a little. This morning , the patient felt nausea and vomited twice, the materials were something from stomach without bile , with fever and tested her body temperature at high as 38.3C, without diarrhea ,without referred pain at other place , no jaundice ,hematuria. at the same time the abdominal pain was severe .so the patient came to our hospital for advanced diagnosis and treatment. The doctors at the emergency of surgery gave her some tests for blood routine , urine routine ,and B-ultrasound for abdomen. The results :blood routine: WBC 14.3*10 ,N 0.90, L 0.10 ,Hb 13.5g/l .Urine routine :KET +.others were normal. Also no abnormality was found by B-US. Then the doctor had a impression of appendicitis and made her admission. Since suffering the disease the patient was good in consciousness while bad in appetite and sleep , normal of stool and urine .Past history: No history of chronic diseases like hypertension, CAD and mellitus diabetics. No history of hepatitis or AIDS , tuberculosis .No history of trauma and operation. No history of hypersensitivity of any drug or food.Review of Systems:Respiratory system: no history of chronic cough , expectoration, hemoptysis , chest pain , or short of breath.Circulation system: no history of dyspnea or edema at the lower limbs. No history of palpitation or chest pain. No history of hypertension.Digestive system: no history of anorexia, abdominal distention, regurgitation. 2 days of right lower abdominal pain with nausea and vomiting. No history of constipation , diarrhea ,melena and so on.Urogenital system: no history of swollen eyelids or lumbago. No frequent micturition, urgency of micturition or urodynia. No dysuria ,hematuria or retention and incontinence of urine .no history of acute or chronic nephritis.Hemopoeltic system: No pallid countenance ,weakness,dizziness , daze ,tinnitus. No history of bleeding and repeated infections.Metabolic and Endocrine system: no abnormal cold or hot feeling, hidosis,headache,weakness,impaired vision,polyphagia ,polyuria ect.normal distributed hair.no change of temper and intelligence.Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal sensation or motion. No change of personality .no mania ,depression or hallucination.Motor system: no limbs and muscle numbness ,pain ,spasm, atrophy or palalysis. No joint red swollen, hot ,pain or limitation of motion. No trauma or fracture.Personal history : born in her native place and living in tianjin. No history of exposure to poison.No habits of drinking or smoking.Marital History: regular in menstruation,3-5days/28 days. Medium in amount and no dysmenorrhea. Married at 24 years old and having a boy . her child and husband both health.Family history: denying the family history of malignancy, tuberculosis, MD, CAD, hypertension ect. Physical Examination Temperature: 38.5C pulse rate: 85/min respiratory rate: 20/min blood pressure:110/79mmHgGeneral appearance : normal development and medium in nourished ,no abnormal consciousness, good corporation in examination. Free position, uncomfortable looking with much sweat.Skin and mucous membrane : No pallid , cyanosis, and jaundice . no abnormal pigmentation and depigmentation . no erythma annulare, petechia and spider angioma. Normal elasticity of skin, no edema.Superficial lymph nodes: no enlargement of the superficial lymph nodes.Head and its organs:Skull: no deformity, tenderness or mass. Evenly distributed hair with black color and shine.Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids. No pallor, granules ,follicles pectechiae of conjunctivae . transparent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization. No exophthalmos or enophthalmos.free motions of the eye balls in any direction. Equal and round pupils at both sides with diameter 4mm, normal and active direct and indirect light reflexs,normal accommodation and convergence reflexes. Vision , visual field and eyegroud not examined.Ears:no deformity .no abnormal secretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.Nose: no deformity. No deviation of septum nasi. No ala flutter. No edema ,abnormal secretion ,and congestion of the membrane . good ventilation. No tenderness in any paranasal sinuses.Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth, no caries. No bleeding or congestion ,lead line in gums. Thin and slight yellow fur coated on the tongue ,with normal in motion. No redness and congestion in pharynx ,no deviation of uvulae. No edema in tonsils.Neck: symmetry . no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins. No rigidity .no enlargement of thyroid glands ,and the trachea in the centeral position. No murmur. Negative of hepatojugular reflux.Chest: symmetry. No deformity. No barrel chest ,pigeon chest or funnel chest. No tenderness over the chest .the thoracic respiration present. R 20/min, symmetry in both sides. Symmetry and no abnormality of the 2 breasts.Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration. Respiratory movement equel in both sides and regular . no dyspnea or three concave sign.Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus. No pleural friction fremitus . no subcutaneous crepitation.Percussion: resonance in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th ,8th ,10th on midclavicular ,midaxillary,midcapular line respectively. The movement of the lower margin of the lungs: 6 cm.Auscultation: clear of vesicular breathing sounds all over the lung fields. No moist rales or rhonchis .normal of vocal resonance. No pleural friction sound.Heart:Inspection: no precordial bulging. Apical impulse in the 5th ICS 1cm inside of left midclavicular line with an area of 2 cm in diameter.Palpation: apical impulse and its area as that in inspection. Regular ,normal intensity. No pericardial friction rubs or thrill.Percussion: relative cardiac dullness shown as follows:Right (cm)ICS Left (cm)2224367 The distance between the left midclvicular line and the midsternal line is 8cm.Auscultation: HR 85/min with regular rhythm, heart sounds clear and intensive . no murmurs at any auscultation area of the valvula. No pericardical friction sound.Radial arteries: pulse rate 85/min, with regular rhythm, equal in both sides, normal intensity .Perivascular signs: no capillary pulsation, water hammer pulse ,pistol-shot sounds and Duroziezs murmur . no pulse deficit, and pulse alternant. Abdomen:Inspection: symmetry. No bulge abdomen ,abdominal distention . weak abdominal respiration. No visible gastrointestinal waves. No varicosity , scar ,petechia at the abdominal Skin.Palpation: soft, tenderness in the right lower abdomen, with rebounding tenderness, slight tightened abdominal wall. No palpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphys sign.Kidneys: not palpable. No tenderness in the any site of kidneys or ureters. Spleen: not palpable.Percussion: tympany in all over the abdomen, no shifting dullness. No percussive pain of liver and spleen. The upper margin of liver at the 5th ICS in the right midcalvicular lineAuscultation: weak borhorygmus, 2/min, no murmur of vessels. No friction rubs .Anus and rectum: not examined.Spine: no lordosis, kyphosis, or scoliosis. No rigidity.free motion. No tenderness or punching tenderness.Extremities: symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities.Nerve system: the extremities move freely. And the strength of muscle is at the 5th grade .normal tension of muscles. Normal sensation. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal. as knee jerk and Achilles jerk. babinskis oppenheims,chaddocks,gordons negative. No patellar or ankle clonus.Laboratory findings:Blood routine: WBC 14.3*10 ,N 0.90, L 0.10 ,Hb 13.5g/l .RBC 4.21*1012/l ,plt 264*10/l.Urine routine :KET +.ph 6.8 PRO,BLD,LEU negative,others were normal. B-US: normal of liver ,gallbladder, spleen, pancreas,kidneys. Summary . The patient named GuoYing ,31 years old, female, admitted to our hospital with the chief complaint of right lower abdominal pain for 2 days accompanying with nausea ,vomiting and fever for 1 days.2 days ago, without any reason, the patient felt abdominal pain. At the beginning the site of pain was not so clear and the pain was not very severe. Without fever ,nausea or vomiting, diarrhea and so on. So the symptom did not cause any attention. But some hours later , the symptom developed to be more severe and the site was more clear mainly at the right lower abdomen then the patient went to the clinic nearby, and got some drugs for abdominal pain. After that the symptom improved a little. This morning , the patient felt nausea and vomited twice, the materials were something from stomach without bile , with fever and tested her body temperature at high as 38.3C, without diarrhea ,without referred pain at other place , no jaundice ,hematuria. at the same time the abdominal pain was severe .so the patient came to our hospital for advanced diagnosis and treatment. The doctors at the emergency of surgery gave her some tests for blood routine , urine routine ,and B-ultrasound for a