妇科英文病历模板篇一:妇产科英文模板CASEMedical Number: 756943General informationName: Yue Jun-rongAge: Forty- two years old Sex: FemaleRace: Han Occupation: UnemploymentNationality: ChinaMarital status: Married Address : Xiaochang county of Xiaogan cityin Hubei. Tel: 4835963Date of admission: Feb.27th, 2003Date of record: 3pm, Feb.27th, 2003 Complainer of history: the patient herselfReliability: ReliableChief complaint: The patient was found “myoma ofuterus” over two years ago and menometrorrhagia for 5 months.Present illness: In 1999, the patient was found “myoma ofuterus” in a physical examination. But she had nothing1uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.Past historyOperative 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 respiratory 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 andmucocutaneous bleeding. Endocrine system: Noacromegaly. No excessive sweats.2Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examinationT 36.8?, P 80/min, R 20/min, BP 120/80mmHg. 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.HeadCranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.3Ear: 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. Septum 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 size. Direct and indirect pupillary reactions to light were existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. 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 widened. No tenderness.Thorax: Symmetric bilaterally. No deformities.4Breast: 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 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 precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardialfriction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. Nopathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses 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 all5limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/lUrine-Rt: SG 1.070 pH 6.0B-ultrasound: 1. subserous myoma of uterus2. position of loop is normalHepatic function: NormalPT & APTT: NormalProfessional ExaminationPudendum: Married typeVagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth.Others: NormalHistory summary1. Patient was female, 45 years old2. The patient was found “myoma of uterus” over two6year ago and menometrorrhagia for 5 months..3. No special past history.4. Physical examination showed no abnormity in lung, heart and abdoman. Professional examination can been seen above.5. investigation information: see aboveImpression: subserous myoma of uterusSignature: He Lin (95-10033)来源:杨帆| 分享(7) | 浏览(49)篇二:妇产科英文病历Inpatient HistoryName: Yali ZhouSex: FemaleAge: 38year Ward: No.8 Bed: No.816 Marital status: Married Birthplace: ShanghaiNationality: Han Provider: Patient, reliable. Record date: 2005-12-13G & O History: GW: 30+5weeks, G2P0, LMP: 2005-5-10; EDC: 2006-2-17Chief Complaint: G2P0, GW: 30+5weeks. This patient presents hypertension for 3 months, and systemic edema for 2 weeks.7History of Present illness:The patient had regular menses previously. LMP: 2005-5-10; EDC:2006-2-17. Uric HcG test was positive after 40 days of amenorrhea. Fetal movements were felt in 4 months’ gestation. In 12+2weeks’ gestation, the patient’s blood pressure was found 160/90 mmHg when shecompleted her first ante-partum examination in Hospital of Women and Children’s Health in Huangpu District. Therewas no symptoms at that time, and she didn’t take anytreatment. Half a month ago, she presented edema on both the lower extremities, which expanded to the whole body gradually. She came to our hospital on Dec, 5th and took her sencond ante-partum examination. The bp was200/160mmHg, and uric protein(++) on dipstick test. She has occasional headaches, but no epigastric pain, no visual disturbances, no oliguria, no nausea or vomiting, no thoracic pain. She was admitted on 2005-12-6.After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation.Past history: Patient denies history of hepatitis and tuberculosis. No history of allergies. Vaccinated regularly. Past medical history is uemarkable. Surgical history denied.8No history of severe trauma and transfusion.Review of systems:Respiratory system: No history of chronic cough or breathlessness. No hemoptysis or dyspnea.Cardiovascular system: No precordial pain. No palpation. No syncope. For details see present history.Gastroentestinal system: No history of chronic abdominal pain and diarrhea; No nausea or vomiting; No hematemesis and blood stool.Endocrinic system: No polydipsia or polyphasia or polyuria. No sudden change of character and intelligence.Hematologic system: No bruises or abnormal hemorrhage. No recurrent oral ulcer and gingival bleeding.Genitourinary system: No decreased libido; No vaginal dryness or vaginal bleeding; History of STD denied; No urinary frequency. No precipitant urination or dysuria. No hematuria or proteinuria.Neuropsychiatric system: No convulsion or anesthesia. No headaches. No abnormal orientation. No deterioration of memory or intelligence.Locomotor system: No arthralgia, no muscular atrophies or dystrophies.9Personal History:Born and grown up in Shanghai. Patient denied history of tobacco or alcohol use.Marital and Childbearing history: Married. 0-0-1-0; She had an abortion in 3 months’ gestation in Dec., 2004. Birthcontrol has been instructed.Family history: The patient’s Mother and a sister sufferedfrom hypertension. No family history of DM or stroke. No family history of nervous or mental diseases.Physical ExaminationT: 37? P: 89/minR: 20/minBP: 180/120mmHgGeneral appearance: Patient is a 38 years old female who appears pleasant, in no apperant distress, given her age, well developed andwell nourished. Oriented to person, place and time.Lymph nodes: Not enlarged.Skin: No jaundice or rashes. No cyanosis and bruises. No edema.Head: Skull and scalp normal. No tenderness. No loss of hair.Eyes: No edema in eyelids, no ptosis, no conjunctivalcongestion.Width of palpebral fissures is normal. No10jaundice. Pupil’s size and shape is normal. Corneal is clear. No exophthalmos.Ears: Auditory acuity is excellent. No ear purulent discharge.Nose: Shape is normal. No obstruction. No deviation of nasal septum.Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tonsils not enlarged.Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass.Lung:Inspection: Respiration regular. Degree of expansion is symmetry.Plapation: Tactile fremitus symmetrical.Percussion: extensive resonance to percussion.Ausculation: Clear to ausculation with no rubs noted.Heart:Inspection: No abnormal pulsation or retraction.Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the left mid-clavicular line.11Percussion: The border of cardiac is not enlarged.Ausculation: The heart sounds were of good quality and the rhythm was regular.Radial pulse is normal.Abdomen:Inspection: Universial abdominal bulge. Dilated veins observed.Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy’s sign is negative. For details seeobstetric examination.Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space.Ausculation: Bowl sound clear. 4/min.Spine and extremities: Severe edema in both lower extremities. No clubbed finger. No disorder of the movement of axial and appendicular bones.Reflex: Symmetrical, equal without pathological responses. Babinski sign and Kernig sign and hoffmann sign are all negative.Obstetric examinationPatient appears pleasant, given her age, well developed and12well nourished. No jaundice. No enlarged lymph nodes.Fetus: Abdominal girth: 93cm; height of fundus: 29cm; estimated fetal weight: 1600g; fetal position: LOA; point of fetal heart tone: ; fetal heart rate: 148/min; FM: active.Pelvis: 24-17-19-9 cm.Anorectal examination: fetal presentation: N/A; sincipital presentation: N/A; fetal membrane: not ruptured. Amniotic fluid: N/A;Flexion of knee: active.Laboratory and special examinationthDec. 6, Blood Rt: Hb: 121g/L; PLT 136×10e9Urine Rt: uric protein(++); occlude blood: (+++)Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL:51mm; HL:49mm. fetal presentation: head; Position of placenta: right wall of uterus.Thickness of placenta: 23mm. Degree of placental maturity: ?; fetal heartbeat and fetal movement seen; amniotic fluid: 64mm. There is no hematocoelia or ascites. The lower edge of placenta is1323mm from thecervix.Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.Fetal heart rate: 145/minDec. 8th, 24h uric protein: 7.5gDec.10th, serum potassium: 3.9mmol/LScr: 86umol/LALT: 25U/L ; AST: 30U/LFeatures of the case:1. Female, 38years old, G2P0, GW: 30+5weeks.2. This patient presents hypertension for 3 months, andsystemic edema for 2 weeks.3. PE: BP: 180/120mmHg. Obstetric exam: Fetus: Abdominal girth: 93cm; height offundus: 29cm; estimated fetal weight: 1600g; fetal position:LOA; point of fetal hearttone: ; fetal heart rate: 148/min; FM: active.Pelvis: 24-17-19-9 cm.Flexion of knee: active.4. Laboratory and special exam:Dec. 6th, Blood Rt: Hb: 121g/L; PLT 136×10e9Urine Rt: uric protein(++); occlude blood: (+++)14Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL:51mm;Degree of placental maturity: ?; fetal heartbeat and fetalmovementseen; amniotic fluid: 64mm.Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.Fetal heart rate: 145/minDec. 8th, 24h uric protein: 7.5gDec.10th, serum potassium: 3.9mmol/LScr: 86umol/LALT: 25U/L ; AST: 30U/LDiagnosis and differential diagnosis:Diagnosis: 1. Severe pre-eclampsia. This patient is a 38-year-old woman, who presents with hypertension and edema. Pre-eclampsia is hypertension associated with proteinuria and edema, occurring primarily in nulliparas after the 20th gestational week and most frequently near term. Other clinical findings of the patient include uric protein (++),etc. These lead to the diagnosis of pre-eclampsia, which feature the clinic status of the latter. The patient has (1) blood pressure 180/120mmHg(160/110mmHg);15(2)proteinuria(++) on dipstick testing and 7.5g (5g)in a 24-hour period. Conclusively, she can be classified as severe pre-eclampsia.Pre-eclampsia is a multisystemic syndrome, primary investigations reveal that she has occasional headaches, but no epigastric pain, no visual disturbances, no oliguria, no nausea or vomiting, no thoracic pain, indicating that there are no many complications at present. Further evaluations are indispensable, which requires more careful investigations.2. Chronic essential hy pertension. The patient’shypertension began from the 12w of gestation, which indicate thatshe has chronic hypertension. Besides, she has a family history of hypertension. After all, she doesn’tpresent severe complaints when her blood pressure were as high as 200/160mmHg. All these lead to the diagnosis of chronic hypertension. To confirm the diagnosis, the blood pressure after delivery should be evaluated.Differential diagnosis: 1. chronic essential hypertension associated with pregnancy. Essential hypertension associated with pregnancy can also cause a very high blood pressure. However, given the age,proteinuria and edema are possibly not complications of hypertension, indicating that she has16superimposed pre-eclampsia. Besides, the symptoms of proteinuria and edema are temporally associated with gestation.2. Chronic hypertension due to renal disease. This includes chronic hypertension due to interstitial nephritis, chronic glomerulonephritis, SLE, diabetic glomerulosclerosis, and so on. In these occasions, the patient would also possibly present hypertension, proteinuria and edema, but her proteinuria was found recently and she didn’t have any symptoms associated with renal diseases previously. In addition, her serum creatinine is in the normal scale (Scr: 86umol/L), which contradicts the hypothesis that she has a renal disease. So the diagnosis of chronic hypertension due to renal disease is not considered at present.Further investigations and treatments:1. Close observation and monitoring, plus quick evaluation: daily weighing; q4-6h monitoring of blood pressure; daily monitoring ofprotein in urine; Regular liver and kidney function testing; Ultrasound of the abdomen; Fetus heartbeat monitor; Conduct ophthalmoscopy examination to evaluat e the severity of the patient’s condition; Conduct PT,APTT, FDP, 3P test to evaluate the coagulant function.172. Rests: Lie in bed on left side.3. Magnesium sulfate administration with close observation offlexion of knee, respiratory rate and urine.4. Control hypertension with Labetalol or Nitroglycerin. The goal of bp control is diastolic pressure《110mmHg andMAP《140mmHg.5. Administer furosemide to control edema.6. Cautious evaluation of the maternal and fetal complications and take action correspondingly. Severe maternal complications include edema of the brain, pulmonary edema; DIC; HELLP syndrome; renal failure. Indicative symptoms include headache, epigastric pain, visual disturbances, oliguria, nausea and vomiting, thoracic pain, etc.7. Use corticosteroids to accelerate fetal lung maturity.8. Delivery. In an effort to reduce perinatal morbidity and mortality, delivery should be delayed. If the patient develops into the following conditions: 1.Blood pressure consistently higher than 100mmHg diastolic in a 24h period or confirmed higher than 110mmHg; 2. Rising serum creatinine; 3. Persistent severe headache; 4. epigastric pain; 4. abnormal liver function tests; 5: Thrombocytopnia; 6: HELLP18syndrome; 7: Eclampsia; 8: Pulmonary edema; 9: Abnormal antepartum fetal heart rate testing; 10: SGA fetus with failure to grow on serial ultrasound examinations.Clinic diagnosis: 1. Severe pre-eclampsia2. Chronic essential hypertension Signiture: /Jacky Luo 篇三:妇科英文病历CASEMedical Number: 756943General informationName: Yue Jun-rongAge: Forty- two years oldSex: FemaleRace: HanOccupation: UnemploymentNationality: ChinaMarital status: MarriedAddress: Xiaochang county of Xiaogan city in Hubei. Tel: 4835963 Date of admission: Feb.27th, 2003 Date of record: 3pm, Feb.27th, 2003 Complainer of history: the patient herself Reliability: Reliable Chief complaint: The patient was found “myoma ofuterus” over two years ago and menometrorrhagia for 519months.Present illness: In 1999, the patient was found “myoma ofuterus” in a physical examination. But she had nothing uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.Past historyOperative 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 respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease.20Hematopoietic system: No history of anemia and mucocutaneous bleeding.Endocrine system: No acromegaly. No excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examinationT 36.8?, P 80/min, R 20/min, BP 120/80mmHg. 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 not21enlarged. HeadCranium: Hair was black and well 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. Septum 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 wereround and equal in size. Direct and indirect pupillary reactions tolight were existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. 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 subcutaneous22emphysema. Intercostal space was neither narrowed nor widened. No tenderness.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 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 precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardialfriction sound. Border of the heart was normal. Heart sounds were strongand no splitting. Rate 80/min. Cardiac rhythm was regular. Nopathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Therewas not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill23negative. 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 anypathological ones.Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/lUrine-Rt: SG 1.070 pH 6.0B-ultrasound: 1. subserous myoma of uterus2. position of loop is normalHepatic function: NormalPT & APTT: NormalProfessional ExaminationPudendum: Married typeVagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth. Others: Normal24History summary1. Patient was female, 45 years old2. The patient was found “myoma of uterus” over twoyear ago and menometrorrhagia for 5 months..3. No special past history.4. Physical examination showed no abnormity in lung, heart and abdoman. Professional examination can been seen above.5. investigation information: see aboveImpression: subserous myoma of uterusSignature: He Lin (95-10033)25。
