英语 病例 模板

CASE

Medical Number: 682786 General information

Name:Wang Runzhen Age: Forty three

Sex: Female

Race:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500

Date of admission:Jan 11st, 2001

Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable

Chief complaint: Right breast mass found for more than

half a month.

Present illness: Half a month ago, the patient suddenly felt

pain in her right chest when she put up her hand. After

touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the

pain became more and more serious, so the patient went to

tumour hospital and received 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 her spiritedness and physical energy are normal. Defecation and urination are normal, too.

Past history

Operative history: Never undergoing any operation. Infectious history:No history of severe infectious disease.

Allergic history: She was not allergic to penicillin or sulfamide.

Respiratory system: 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 and mucocutaneous bleeding.

Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness. Personal history

She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.

Menstrual history:The first time when she was 14. Lasting 3 to 4 days 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 examination

T 36.4℃,P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not

enlarged.

Head

Cranium:Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.

Ear:Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.

Nose:No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.

Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.

Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.

Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.

Chest

Chestwall:Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.

Thorax: Symmetric bilaterally. No deformities. Breast:Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine.

Lungs:Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally.

No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.

Heart:No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left 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 murmurs.

Abdomen:Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs. Extremities: No articular swelling. Free movements of all limbs.

Neural system:Physiological reflexes were existent without any pathological ones.

Genitourinary system: Not examed.

Rectum: not exaned

Investigation

No.

Professional Examination There are a about 3*3*2 cm mass in outer-up field of her right breast. It is hard but no tendness. It can be moved and its surface is smooth. The skin of her breast is normal. Corresponding superficial lymph nodes don’t enlarge.

History summary

1.Patient was a teacher, female, 43 years old.

2.Right breast mass found for more than half a month.

3.No special past history.

4.Physical examination showed no abnormity in lung, heart and abdoman. Information about her breast can be seen above.

5. Shorting of investigation information.

Impression: Breast cancer (right)

Signature: He Lin

(95-10033)