英语病例模板

1、精品文档CASEChief complaint: Right breast mass found for more than half amonth.Present illness: Half a month ago, the patient suddenly felt painin her right chest when she put up her hand. After touching it,she found a mass in her right breast, but no tendness,and thepatient didnptay attention it. Then

2、the pain became more andmore serious, so the patient went to tumour hospital andreceived 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 herspiritedness and physical energy are normal. Defecat

3、ion andurination are normal, too.Past historyOperative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.General informationName: Wang RunzhenAge: Forty threeSex: FemaleRace: HanOccupation: TeacherNationality: China Maritalstatus: MarriedAddress: NO.

4、38,Hangkong Road, JiefangMedical Number: 682786Rvenue, Hankou, Hubei.Tel: 82422500Date of admission: Jan11st, 2001Date of record: 11Am, Jan11st, 2001 Complainer ofhistory: the patient herselfReliability: Reliable精品文档Allergic history: She was not allergic to penicillin or sulfamide.Respiratory system

5、: 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 andmucocutaneous bleeding.Endocrine system: No acromegaly. No exce

6、ssive sweats.Kinetic system: No history of confinement of limbs. Neuralsystem: No history of headache or dizziness.Personal historyShe was born in Wuhan on Nov 19th, 1957 and almost alwayslived in Wuhan. She graduated from senior high school. Herliving conditions were good. No bad personal habits an

7、dcustoms.Menstrual history: The first time when she was 14. Lasting 3 to 4days 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 examinationT 364

8、C, P 80/min, R 20/min, BP 90/60mmHg. She is welldeveloped and moderately nourished. Active position.The skin was not stained yellow. No cyanosis. No pigmentation.No skin eruption. Spider angioma was not seen. No pittingedema. Superficial lymph nodes were not enlarged.Head精品文档Cranium: Hair was black

9、and well distributed. Nodeformities. No scars. No masses. No tenderness.Ear: Bilateral auricles were symmetric and of no masses.No discharges were found in external auditory canals. Notenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulumnasi. Sep

10、tum nasi was in midline. No nares flaring. Notenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. Noentropion. Conjunctiva was not congestive. Sclera was anicteric.Eyeballs were not projected or depressed. Movement wasnormal. Bilateral pupils were round and equal in size.

11、 Direct andindirect pupillary reactions to light were existent.Mouth: Oral mucous membrane was smooth, and of noulcer or erosion. Tongue was in midline. Pharynx was notcongestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroidwas not enlarged. Trachea was in midl

12、ine. ChestChestwall: Veins could not be seen easily. No subcutaneousemphysema. Intercostal space was neither narrowed norwidened. No tenderness.Thorax: Symmetric bilaterally. No deformities.Breast: Symmetric bilaterally. Neither nipples nor skin wereretracted. Elasticity was fine.Lungs: Respiratory

13、movement was bilaterally symmetric withthe frequency of 20/min. Thoracic expansion and tactilefremitus were symmetric bilaterally. No pleural friction fremitus.Resonancewas heard during percussion. No abnormal breathsound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse or thr

14、ills inprecordial area. The point of maximum impulse was in 5th left精品文档intercostal space inside of the mid clavicular line and not diffuse.No pericardial friction sound. Border of the heart was normal.Heart sounds were strong and no splitting. Rate 80/min.Cardiac rhythm was regular. No pathological

15、 murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominalwall varicosis. Gastralintestinal type or peristalses were notseen. There was not tendernessand rebound tenderness onabdomen or renal region. Liver was not reached. Spleen wasnot enlarged. No masses. Fluidthrill negative. Shifting

16、dullnessnegative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without anypathological ones.Genitourinary system: Not examed. Rectum: not exanedInvestigationNo.Professional ExaminationThere

17、are a about 3*3*2 cm mass in outer-up field of her rightbreast. It is hard but no tendness. It can be moved and itssurface is smooth. The skin of her breast is normal.Corresponding superficial lymph nodes dont enlarge.History summary1. Patient was a teacher, female, 43 years old.2. Right breast mass found for mor