口腔科英文病历.docx

口腔科英文病历.docx

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口腔科英文病历

OralandMaxillofacialSurgeryCompleteMedicalHistory

（Zhangte）

MedicalNumber:

182786

Generalinformation

Name:

Taolili

Age:

Fortyeight

Sex:

Female

Race:

Han

Occupation:

worker

Nationality:

China

Maritalstatus:

Married

Address:

mawangduiRvenue,changsha,Hunan.

Tel:

Dateofadmission:

Jun20st,2013

Dateofrecord:

11Am,Jun20st,2013

Complainerofhistory:

thepatientherself

Reliability:

Reliable

Chiefcomplaint:

lowerincisorsgingivaemassfoundformorethan3month.

Presentillness:

3monthago,thepatientsuddenlyfoundasmallmassonlowerincisorsgingivae.Aftertouchingit,shefoundamasstendness,Shedidnotgetfever,dizziness,vertigoandheadache.thepatientdidn’tpayattentionit.Thenthemassbecamemoreandmorebigger,sothepatientshecametoourhospitalandaskedforanoperation.

Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,too.

Pasthistory

Operativehistory:

Neverundergoinganyoperation.

Infectioushistory:

Nohistoryofsevereinfectiousdisease.

Allergichistory:

Shewasnotallergictopenicillinorsulfamide.

Respiratorysystem:

Nohistoryofrespiratorydisease.

Circulatorysystem:

Nohistoryofprecordialpain.

Alimentarysystem:

Nohistoryofregurgitation.

Genitourinarysystem:

Nohistoryofgenitourinarydisease.

Hematopoieticsystem:

Nohistoryofanemiaandmucocutaneousbleeding.

Endocrinesystem:

Noacromegaly.Noexcessivesweats.

Kineticsystem:

Nohistoryofconfinementoflimbs.

Neuralsystem:

Nohistoryofheadacheordizziness.

Personalhistory

ShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.

Menstrualhistory:

Thefirsttimewhenshewas14.Lasting3to4dayseverytimesanditscycleisabout30days.

Obstetricalhistory:

Pregnacy3times,oncenatureproduction,abortiontwice.

Contraceptivehistory:

Notclear.

Familyhistory:

Hisparentshavebothdied.

Physicalexamination

T℃,P80/min,R20/min,BP90/60mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.

Head

Cranium:

Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.

Ear:

Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.

Nose:

Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.

Eye:

Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.

Neck:

Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.

Chest

Chestwall:

Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.

Thorax:

Symmetricbilaterally.Nodeformities.

Breast:

Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.

Lungs:

Respiratorymovementwasbilaterallysymmetricwiththefrequencyof20/min.Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.

Heart:

Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate80/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.

Abdomen:

Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Therewasnottendernessandreboundtendernessonabdomenorrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.

Extremities:

Noarticularswelling.Freemovementsofalllimbs.

Neuralsystem:

Physiologicalreflexeswereexistentwithoutanypathologicalones.

Genitourinarysystem:

Notexamed.

Rectum:

notexaned

Investigation

No.

ProfessionalExamination

Oralmucousmembranewassmooth,andofnoulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotwithpoororalhygienehasmuchdentalcalculus.Thereareaabout2*2*massonlowerincisors（33-41）gingivae.Itistenderbutnotbleed.Itcannotbemovedanditssurfaceissmooth.Correspondingsuperficiallymphnodesdon’tenlarge.

Impression:

Epulis

Signature:

Zhangte

Hospitalcourserecordforthefirsttime

2013-6-208:

50

1、Characteristicsofcases：

1.Clinicalpresentation:

Patientwasaworker,female,48yearsold.

2.lowerincisorsgingivaemassfoundformorethan3month.

3.Nospecialpasthistory.

4.Physicalexaminationshowednoabnormityinlung,heartandabdoman.Informationaboutheroralcanbeseenabove.

5.Shortingofinvestigationinformation.

℃,pulse80,respirations20,bloodpressure90/60.

二、Examinationtodiscuss

diagnosticbasis：

incisorsgingivaemassfoundformorethan3month。

2.Shedidnotgetfever,dizziness,vertigoandheadache.Thereareaabout2*2*massonlowerincisors（33-41）gingivae.Itistenderbutnotbleed.Thereareaabout2*2*massonlowerincisors（33-41）gingivae.Itistenderbutnotbleed.

differentialdiagnosis：

Gingivalcarcinoma：

Exceptfastgrowth,itcanappearlocalcanker,pain,involvingrelatedtoteeth.

ADMITTINGDIAGNOSIS:

Epulis

三、Caseclassification：

A

四、Treatmentplan：

improvetheroutinemouthcleanoperation.

Xuyuguo

Hospitalrecords

2013-6-21

Thepatientwashospitalizedonthissuddenlyfoundasmallmassonlowerincisorsgingivae3monthago.transparentmildredness,liningcolorisnormal,Patientsusuallyingoodhealth.Blood,urine,dungroutinehasbeensent,liverandkidneyfunctionchecklisttofillin,checkthedoctor'sadvicealreadybiopsyforthediseasedtissuehasbeensent.

Xuyuguo

2013-6-23

ThismorningPro.zhangvisits,thediagnosisandtreatmentofputforwardthefollowingopinions:

PathologicalbiopsyresulthasshownEpulis.Allinvestigationisnormal.Accordingtotheclinicalmanifestationsofit,thisdiseaseThediseasecanbediagnosedwithtumorresectionCanbeimposedshouldbewholemouthcleanwillbedoneateightontomorrowmorning.

Zhangte/Xuyuguo

2013-6-24

PreoperativeSUMMARY

Patientwasaworker,female,48yearsold.lowerincisorsgingivaemassfoundformorethan3month.Nospecialpastexaminationshowednoabnormityinlung,heartandabdoman.Informationaboutheroralcanbeseeninvestigationisteethhavebeencleaned.Surgicaltreatmentplan:

（1）pastoperativebiopsytodeterminethetumornature;

（2）Completeremovalofthetumorandspreadoftheperiodontalmembrane,teethandgums.（3）amandibulardefectshouldstilldependingonthenatureofthetumorandthenmakeadecisionwhethertoimmediatelybonegraft,butshouldbereadytoimmediatelybonegraft.（4）preoperativeforteethcleaninganduseofantibiotics.

Xuyuguo

2013-6-258:

15

Operationrecords

MakeRoutinelocalanesthesiaonthepatientsupine,disinfectionandshoptowelsaccordingtoMaxillofacialsurgeryroutine.lumpcompletelyandspreadoftheperiodontalmembrane,andgumsbeenremovedwithelectricityknife.hydrogenperoxideandsalineflushwassenttoPathologicalpatientwentbackthewardsafetylyat9:

30,Thesurgerywasover.

Zhangte

2013-6-26

Pastoperativerecords

T℃,P80/min,R23/min,BP100/60mmHg.Patientsfeelthewoundandteethpainissevere,thewoundnearswollengums,jawwascoveredwithalittlefake.ContinuetoAnalgesic,attentiontomaintainoralhygiene.Patientsrequiretodischangetomorrow,heWouldbeapprovedtoagreewith.

Zhangte

DISCHARGERECORD

DATEOFADMISSION:

Jun20st,2013

DATEOFDISCHARGE:

Jun26st,2013

Numberofdaysinhospital:

6Days

ADMITTINGDIAGNOSIS:

Epulis

BRIEFHISTORY

PATIENTname:

Taolili,AGE:

48

3monthago,thepatientsuddenlyfoundasmallmassonlowerincisorsgingivae.Aftertouchingit,shefoundamasstendness,Shedidnotgetfever,dizziness,vertigoandheadache.thepatientdidn’tpayattentionit.Thenthemassbecamemoreandmorebigger.

REVIEWOFSYSTEM

Shehashadnoheadache,fever,chills,diarrhea,chestpain,palpitations,dyspnea,cough,hemoptysis,dysuria,hematuriaorankleedema.

PASTMEDICALHISTORY

Shehashadnoprevioussurgery,accidentsorchildhoodillness.

SOCIALHISTORY:

Shehasnohistoryofexcessivealcoholortobaccouse.

FAMILYHISTORY

Shehasnofamilyhistoryofcardiovascular,respirataryandgastrointestinaldiseases.

PHYSICALEXAMINATION

Temperature℃,pulse80,respirations20,bloodpressure90/60.General:

Plumpgirlinnoapparentdistress.HEENT:

Shehasnoscalplesions.Herpupilsareequallyroundandreactivetolightandaccommodation.Extraocularmovementsareintact.Scleraeareanicteric.Oropharynxisclear.Thereisnothyromegaly.Thereisnocervicalorsupraclvicularlymphadenopathy.Cardiovascular:

Regularrateandrhythm,normalS1,S2.Chest:

Cleartoauscultationbilateral.Abdomen:

Bowelsoundspresent,no