英语 病例 模板

2021年1月26日发(作者：断交)
CASE


Medical Number: 682786
General information
Name:

Wang Runzhen
Rvenue,
Hankou,
Hubei.
Age:
Forty three
Tel: 82422500
Sex:
Female

Date
of
admission:

Jan
Race:

Han
11st, 2001
Occupation:
Teacher
Date
of
record:
11Am,
Nationality:

China
Jan 11st, 2001
Marital status:
Married
Complainer
of
history:
Address:
NO.38,
the patient herself
Hangkong
Road,
Jiefang
Reliability:
Reliable

Chief
complaint:
Right
breast
mass
found
for
more
than
half a month.
Present illness:
Half a month ago, the patient suddenly felt
pain
in
her
right
chest
when
she
put
up
her
hand.
After
touching
it,
she
found
a
mass
in
her
right
breast,
but
no
tendness,
and
the
patient
didn’t
pay
attention
it.
Then
the
pain became more and more serious, so the patient went to
tumour
hospital
and
received
a
pathology
centesis.
Her
diagnosis was breast cancer. Then she came to our hospital
and asked for an operation.





Since
onset,
her
appetite
was
good,
and
both
her
spiritedness
and
physical
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 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
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 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.
Menstrual
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/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