英语病例模板
英语病例模板
英语病例模板
CAＳＥ
ＭeｄicａlNuｍbｅr:68２７86
Generａlｉnfｏrｍａtｉon
Nａme:WangRｕnzhｅn
Ａge:Foｒｔythrｅe
Ｓｅx:Femaｌe
Race:Ｈan
Occupaｔion:Teachｅr
Natｉoｎａlｉｔy:China
Mａrｉtａｌｓtatus:Married
Address:NO、３8,ＨangｋｏnｇRoad,JiefaｎgＲvenｕe,Hankｏu,
Daｔeｏfaｄmiｓｓion:Ｊａn１1sｔ,20０1
Ｄａｔeofrｅcord:11Am,Jan11st,2001
pｌaiｎerofhisｔoｒｙ:thepatｉenｔheｒself
Ｒeliabiliｔy:Reliable
Chiefplaint:Rightｂreａstmassfoundfoｒmoｒethanhaｌfaｍontｈ、
Presenｔillｎess:Halｆamonthａgo,thｅｐatieｎtsuddeｎlyｆeｌｔpaininhｅｒｒiｇhtchｅsｔwhensｈeputupherhａnd、Afterｔｏuchingｉt,shefoｕnｄamasｓinｈerｒｉghｔbreast,bｕｔnoteｎdnｅss,aｎｄthｅpaｔiｅｎtdｉdn’ｔpａyaｔtｅｎtiｏｎiｔ、Ｔhenthｅpainbecａmemoreandｍoreserious,sothepatieｎtweｎtｔotumourhｏspitalanｄｒeceivｅdapaｔｈoloｇycｅntｅsis、Ｈerdｉagnosiswasbｒeaｓtcancer、Theｎshecametoourhｏspｉtalanｄａｓｋedｆoranｏpｅraｔion、
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、
Obstetｒｉc