英语病例模板

1、General informationName: Wang RunzhenAge: Forty threeSex: FemaleRace: HanOccupation: TeacherNationality: ChinaMarital status: MarriedAddress:NO.38,Hangkong Road, JiefangCASEMedicalNumber:682786Rvenue,Hankou,Hubei.Tel:82422500Dateofadmission:Jan11st,2001Dateofrecord:11Am,Jan11st,2001Complainerofhisto

2、ry:thepatientherselfReliability:ReliableChiefcomplaint:Rightbreastmassfoundformorethanhalfamonth.Presentillness:Halfamonthago,thepatientsuddenlyfeltpaininherrightchestwhensheputupherhand.Aftertouchingit,shefoundamassinherrightbreast,butnotendness,andthepatientdidnptayattentionit.Thenthepainbecamemor

3、eandmoreserious,sothepatientwenttotumourhospitalandreceivedapathologycentesis.Herdiagnosiswasbreastcancer.Thenshecametoourhospitalandaskedforanoperation.Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,too.PasthistoryOperativehistory:Neve

4、rundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofg

5、enitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegradua

6、tedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas14.Lasting3to4dayseverytimesanditscycleisabout30days.Obstetricalhistory:Pregnacy3times,oncenatureproduction,abortiontwice.Contraceptivehistory:Notclear.Familyhistory:Hisparentshav

7、ebothdied.PhysicalexaminationT36.4,P80/min,R20/min,BP90/60mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.HeadCranium:Hairwasblackandwelldistri

8、buted.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasa

9、lsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Oralmucousmembranewassmooth,andof

10、noulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotenlarged.Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.Thorax:Sym

11、metricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof20/min.Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercu

12、ssion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate

13、80/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Therewasnottendernessandreboundtendernessonabdomenorrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Fluidthrillnegative.Shi

14、ftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.Genitourinarysystem:Notexamed.Rectum:notexanedInvestigationNo.ProfessionalExaminationThereareaabout3*3*2cmmassinouter-upfieldofherrightbreast.Itishardbutnotendness.Itcanbemovedanditssurfaceissmooth.Theskinofherbreastisnormal.Correspondingsuperficiallymphnodesdontenlarge.Historysummary1. Patientwasateacher,female,43yearsold.2. Rightbreastmassfoundformorethanh