口腔科英文病历文档格式.docx
《口腔科英文病历文档格式.docx》由会员分享,可在线阅读,更多相关《口腔科英文病历文档格式.docx(8页珍藏版)》请在冰点文库上搜索。
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.
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.
2013-6-258:
15
Operationrecords
MakeRoutinelocalanesthesiaonthepatientsupine,disinfectionandshoptowelsaccordingtoMaxillofacialsurgeryroutine.lumpcompletelyandspreadoftheperiodontalmembrane,andgumsbeenremovedwithelectricityknife.hydrogenperoxideandsalineflushwassenttoPathologicalpatientwentbackthewardsafetylyat9:
30,Thesurgerywasover.
2013-6-26
Pastoperativerecords
T℃,P80/min,R23/min,BP100/60mmHg.Patientsfeelthewoundandteethpainissevere,thewoundnearswollengums,jawwascoveredwithalittlefake.ContinuetoAnalgesic,attentiontomaintainoralhygiene.Patientsrequiretodischangetomorrow,heWouldbeapprovedtoagreewith.
Zhangte
DISCHARGERECORD
DATEOFADMISSION:
DATEOFDISCHARGE:
Jun26st,2013
Numberofdaysinhospital:
6Days
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