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1、.....OralandMaxillofacialSurgeryCompleteMedicalHistory（Zhangte）MedicalNumber:182786Generalinformation学习参考.....Name:TaoliliAge:FortyeightSex:FemaleRace:HanOccupation:workerNationality:ChinaMaritalstatus:MarriedAddress:NO.138,mawangduiRvenue,changsha,Hunan.Tel:84722500Da
2、teofadmission:Jun20st,2013Dateofrecord:11Am,Jun20st,2013Complainerofhistory:thepatientherselfReliability:Reliable学习参考.....Chiefcomplaint:lowerincisorsgingivaemassfoundformorethan3month.Presentillness:3monthago,thepatientsuddenlyfoundasmallmassonlowerincisorsgingivae.Af
3、tertouchingit,shefoundamasstendness,Shedidnotgetfever,dizziness,vertigoandheadache.thepatientdidn’tpayattentionit.Thenthemassbecamemoreandmorebigger,sothepatientshecametoourhospitalandaskedforanoperation.Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalen
4、ergyarenormal.Defecationandurinationarenormal,too.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circu
5、latorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.学习参考.....Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohi
6、storyofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhens
7、hewas14.Lasting3to4dayseverytimesanditscycleisabout30days.Obstetricalhistory:Pregnacy3times,oncenatureproduction,abortiontwice.Contraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdied.PhysicalexaminationT36.4℃,P80/min,R20/min,BP90/60mmHg.Sheiswelldevelopedand
8、moderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomaw
