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病例报告英文.docx

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病例报告英文.docx

上传人:mkjafow 2019/2/23 文件大小:22 KB

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病例报告英文.docx

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文档介绍:病例报告英文 CASE MedicalNumber: Generalinformation Name:DingZier Age:Fortyseven Sex:Female Race:Han Occupation:farmer Nationality:China Maritalstatus:Married Address:jianlicounty,JingzhouCity,HubeiProvinceDateofadmission:April17,XXDateofrecord:April17,plainerofhistory:thepatientherselfReliability:Reliable plaint:Intermittentlowbackpainfor10years Presentillness:Tenyearsago,thepatientsuddenlyfeltpaininthelowerback,withhematuria,butnourinaryfrequency,urgency,dysuria,feverandothertheLeftkidneystonesremovalsurgery,Patientswithlowbackpainyearsago,patientsfeltintermittentlowbackpainwithurinaryfrequency,urgencyagain,nodysuria,hematuria,feverandothersymptoms,thepatientdidn’-02-24reviewedtheultrasoundfoundthat"Leftkidneystones".Forthesakeoffurthertreatment,etoourhospital,outpatientrevenueto"Leftkidneystones"toourdepartment. Sincetheonset,thepatientsprivateprosecutionspiritedness,appetite,sleepsomewhatless,slightlymoreurination, defecationisnormal, Operativehistory:10yearsago,didkidneystonesremovalsurgery. Infectioushistory:Nohistoryofsevereinfectiousdisease. Allergichistory:Shewasnotallergictopenicillinorsulfamide. Respiratorysystem:Nohistoryofrespiratorysystem:Nohistoryofprecordialpain. Alimentarysystem:Nohistoryofregurgitation. Genitourinarysystem:Nohistoryofgenitourinarydisease. Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding. Endocrinesystem::Nohistoryofconfinementoflimbs. Neuralsystem:Nohistoryofheadacheordizziness. Personalhistory . Menstrualhistory:. Obstetricalhistory:Pregnacy4times,4natureproduction,noabortion. Contraceptivehistory:Notclear. Familyhistory:Herparentsarestillalive. Physicalexamination T℃,P72/min,R18/min,BP116/