妇科英文病历

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1、CASEMedicalNumber:756943GeneralinformationName:YueJun-rongAge:Forty-twoyearsoldSex:FemaleRace:HanOccupation:UnemploymentNationality:ChinaMaritalstatus:MarriedAddress:XiaochangcountyofXiaogancityinHubei.Tel:4835963Dateofadmission:Feb.27th,2003Dateofrecord:3pm

2、,Feb.27th,2003Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Thepatientwasfound“myomaofuterus”overtwoyearsagoandmenometrorrhagiafor5months.Presentillness:In1999,thepatientwasfound“myomaofuterus”inaphysicalexamination.Butshehadnothing

3、uncomfortableandhercatameniawasnormal.SheusedsomeChinesetraditionalmedicine.About5monthsago,shefoundthecycleofhercatameniawasshortenfrom30daysto20daysandtheperiodlastedfrom2daysto4days.Shefeltnopainandthequantitywasnormal.Shewasacceptedinourhospitalandherdia

4、gnosiswas“subserousmyomaofuterus”.Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,too.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.

5、Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsy

6、stem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninHubeionJuly16th,1956andalmostalwayslivedinWuhan.S

7、hegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas14.Lasting2dayseverytimesanditscycleisabout30days.Obstetricalhistory:Pregnacy3times,oncenatureproduction,inducedabortiontwice.Con

8、traceptivehistory:Notclear.Familyhistory:Hisparentsarebothalive.PhysicalexaminationT36.8℃,P80/min,R20/min,BP120/80mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstaine