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1、Oral and Maxillofacial Surgery Complete Medical History（Zhang te） Medical Number: 182786General informationName: Tao liliAge: Forty eightSex: FemaleRace: HanOccupation: worker Nationality: ChinaMarital status: MarriedAddress:NO.138,mawangdui Rvenue,changsha, Hunan. Tel: 84722500Date of admission: Ju
2、n 20st, 2013Date of record: 11Am, Jun20st, 2013Complainer of history: the patient herselfReliability: ReliableChief complaint: lower incisors gingivae mass found for more than 3 month.Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae. After touching it,
3、 she found a mass tendness, She did not get fever ,dizziness, vertigo and headache. the patient didnt pay attention it. Then the mass became more and more bigger, so the patient she came to our hospital and asked for an operation. Since onset, her appetite was good, and both her spiritedness and phy
4、sical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respira
5、tory disease. 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. No excessive sweats. Kin
6、etic system: No history of confinement of limbs. Neural system: No history of headache or dizziness.Personal history She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Me
7、nstrual history: The first time when she was 14. Lasting 3 to 4 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, abortion twice.Contraceptive history: Not clear.Family history: His parents have both died.Physical examination T 36.4, P 80/
8、min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position. The 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.Head Cranium: Hair was black and wel
9、l distributed. No deformities. No scars. No masses. No tenderness. Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Sept
10、um nasi was in midline. No nares flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in s
11、ize. Direct and indirect pupillary reactions to light were existent. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.Chest Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No t
12、enderness. Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine. Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterall
13、y. 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 precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line an
14、d not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses
15、 were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exanedInvestigationNo. Professional Examination Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not
