外科英文病例模板

CASE

MedicalNumber:682786

Generalinformation

Name:DingZier

Age:Fortyseven

Sex:Female

Race:Han

Occupation:farmer

Nationality:China

Maritalstatus:Married

Address:jianlicounty，JingzhouCity,HubeiProvince

Dateofadmission:April17,2013

Dateofrecord:April17,2013

Complainerofhistory:thepatientherself

Reliability:Reliable

Chiefcomplaint:Intermittentlowbackpainfor10years

Presentillness:Tenyearsago,thepatientsuddenlyfeltpaininthelowerback,withhematuria,butnourinaryfrequency,urgency,dysuria,feverandothersymptoms.AftertheLeftkidneystonesremovalsurgery,Patientswithlowbackpainrelief.Fiveyearsago,patientsfeltintermittentlowbackpainwithurinaryfrequency,urgencyagain,nodysuria,hematuria,feverandothersymptoms,thepatientdidn’ttreatit.2013-02-24reviewedtheultrasoundfoundthat"Leftkidneystones".Forthesakeoffurthertreatment,thencometoourhospital,outpatientrevenueto"Leftkidneystones"toourdepartment.

Sincetheonset,thepatientsprivateprosecutionspiritedness,appetite,sleepsomewhatless,slightlymoreurination,defecationisnormal,nosignificantchangesinphysicalweight.

Pasthistory

Operativehistory:10yearsago,didkidneystonesremovalsurgery.

Infectioushistory:Nohistoryofsevereinfectiousdisease.

Allergichistory:Shewasnotallergictopenicillinorsulfamide.

Respiratorysystem:Nohistoryofrespiratorydisease.

Circulatorysystem:Nohistoryofprecordialpain.

Alimentarysystem:Nohistoryofregurgitation.

Genitourinarysystem:Nohistoryofgenitourinarydisease.

Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.

Endocrinesystem:Noacromegaly.Noexcessivesweats.

Kineticsystem:Nohistoryofconfinementoflimbs.

Neuralsystem:Nohistoryofheadacheordizziness.

Personalhistory

ShewasborninJianliCountyandalmostalwayslivedinJianlicounty.Shedidnotgotoschool.Herlivingconditionswereingeneral.Nobadpersonalhabitsandcustoms.

Menstrualhistory:Thefirsttimewhenshewas16.Lasting5to6dayseverytimesanditscycleisabout33days.

Obstetricalhistory:Pregnacy4times,4natureproduction,noabortion.

Contraceptivehistory:Notclear.

Familyhistory:Herparentsarestillalive.

Physicalexamination

T36.3℃,P72/min,R18/min,BP116/76mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.Respiratorymovementwasbilaterallysymmetricwiththefrequencyof18/min.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate72/min.Cardiacrhythmwasnotregular.Nopathologicalmurmurs.Abdomenwasflatandsoft.Nobulgeordepression.Noabdominalwallvarices.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdominal.Therewasreboundtendernessonrenalregion.Liverandspleenwasuntouched.Nomasses.Shiftingdullnessisnegative.Novascularmurmurs.Noedema.Physiologicalreflexeswereexistentwithoutanypathologicalones.

Head

Cranium:Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.

Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.

Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.

Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.

Mouth:Oralmucousmembranewassmooth,andofnoulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotenlarged.

Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.

Chest

Chestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.

Thorax:Symmetricbilaterally.Nodeformities.

Breast:Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.

Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof18/min.Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.

Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate76/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.

Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Thereweretendernessandreboundtendernessonrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.

Extremities:Noarticularswelling.Freemovementsofalllimbs.

Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.

Genitourinarysystem:Notexamed.

Rectum:notexaned

Investigation

February24,2013JianliCountyPeople'sHospitalultrasoundshowed:multiplestonesintheleftkidney,livercalcification.

ProfessionalExamination