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1、1神经内科英文病例模板神经内科英文病例模板篇一：外科英文病例模板篇一：外科英文病例模板CASEMedical Number: 682786General informationName: Ding ZierAge: Forty sevenSex: FemaleRace: HanOccupation:farmerNationality: ChinaMarital status: MarriedAddress:jianli county，Jingzhou City,Hubei Province Date of admission: April 17, 2013 Date of record: Ap
2、ril 17, 2013 Complainer of history: the patient herself Reliability: ReliableChief complaint: Intermittent low back pain for 10 yearsPresent illness: Ten years ago, the patient suddenly felt 2pain in the lower back, with hematuria , but no urinary frequency, urgency, dysuria, fever and other symptom
3、s.After the Left kidney stones removal surgery, Patients with low back pain relief.Five years ago, patients felt intermittent low back pain with urinary frequency, urgency again, no dysuria, hematuria, fever and other symptoms, the patient didnt treat it. 2013-02-24 reviewed the ultrasound(来自来自:www.
4、xLtKwj.coM 小小 龙龙 文档网文档网:神经神经内科英文病例模板内科英文病例模板) found that Left kidney stones .For the sake of further treatment, then come to our hospital, outpatient revenue to Left kidney stones to our department.Since the onset, the patients private prosecution spiritedness, appetite, sleep somewhat less, slightl
5、y more urination,defecation is normal, no significant changes in physical weight. Past historyOperative history: 10 years ago,did kidney stones removal surgery.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide.Respiratory sy
6、stem: No history of respiratory 3disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding.Endocrine system: No acromegaly. N
7、o excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Jianli County and almost always lived in Jianli county. She did not go to school. Her living conditions were in general. No bad personal habits and
8、 customs.Menstrual history: The first time when she was 16. Lasting 5 to 6 days every times and its cycle is about 33 days.Obstetrical history: Pregnacy 4 times, 4 nature production, no abortion.Contraceptive history: Not clear.Family history: Her parents are still alive.Physical examinationT 36.3,
9、P 72/min, R 18/min, BP 116/76mmHg. She is well developed and moderately nourished. Active position. 4The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged. Respiratory movement was bil
10、aterally symmetric with the frequency of 18/min. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 72/min. Cardiacrhythm was not regular. No pa
11、thological murmurs. Abdomen was flat and soft. No bulge or depression. No abdominal wall varices. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdominal. There was rebound tenderness on renal region. Liver and spleen was untouched. No mass
12、es. Shifting dullness is negative. No vascular murmurs. No edema. Physiological reflexes were existent without any pathological ones.HeadCranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.Ear: Bilateral auricles were symmetric and of no masses. 5No disch
13、arges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. No entr
14、opion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion
15、. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor wide
16、ned. No tenderness.Thorax: Symmetric bilaterally. No deformities.Breast: Symmetric bilaterally. Neither nipples nor skin 6were retracted. Elasticity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 18/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse or thrills in pr
