resident admission note产科英文病例

Hospitalization RecordsAdmission number：612984 Identifying information：Name：Zhow Jingzhe Gender：FemaleAge：28 Occupation：Nationality: Han Marital status：MarriedBirth Place: Shanghai Job Unit:Address:Date of admission: Nov. 25, 2010Date of record: Nov. 25, 2010Gestation ages:39+5weeksGeneration: 0 time Pregnancy:1 timeLMP: 2010-02-20 EDC: 2010-11-27Fetal membrane: IntactHas no history of diarrhea, hepatitis, tub bath and sex in the last week.Provider of medical history：Herself (reliable)Chief Complaint:G1P0, having generated for 39+5 weeks, bloody show for 4 hours. Present illness:The pregnant woman has a regular menstrual cycle ordinarily. The periods was 33-35days and lasted for 5 days. Last menstrual period:2010-02-20. The HCG in urine was positive on the 30th days after menelipsis. Morning sickness was not serious. Had no bloody show at the first trimester. Progesterone was used to treat “bellyache”. Feeling fetal movement since the 4th month of pregnancy. Had the 1st antenatal examination when generated for 15 weeks. Has regual obstetrician visit and D screening test was done in Xinhua Hospital. The result of US was normal. GCT:8.9mmol/L, OGTT was normal. During the gestation the pregnant woman has no dizzy, headache, blurred vision, bellyache, vaginal discharge or itch of skin. This morning she had a bloody show without bellyache and vaginal discharge and was admitted. The fetal movement was normal in the last few days. No symptoms of abdominal pain and distension. Her general condition was good. The appetite, sleeping, stools and urine were normal.Past Medical History:Had a history of excision of benign tumor of breast.No history of infectious disease such as hepatitis, tuberculosis,typhoid and schistosomiasis.The history of preventive inoculation was unknown.The penicillin skin test (+). No history of allergy to other drugs or foods.Childbearing history0-0-0-0Review of Systems：Respiratory system: No history of hemoptysis, frequent cough or dyspnea.Circulatory system: No edema in lower extremities. No precourdial pain. No palpitation. No syncope.Digestive system: No anorexia, sour regurgitation or belching. No nausea or vomiting. No history of hematemesis, melena and jaundice. Genitourinary system: No polyuria, urgency micturition, urodynia or decreased markedly sexual desire.Hematologic system: No history of subcutaneous bleeding or anemia. Endocrine system: No polydipsia, polyuria or polyphagia. Neuropsychiatric system: No convulsion and anesthesia. No headaches. No abnormal orientation.Personal History:Born and grow up in Shanghai. Denied Wine and tobacco abuse. No exposure to infective water or poisons.Menstrual history:Menarchal age: UnknownMenstrual period: 5/33-35The latest menstrual time: 2010.2.20Marital History:She got married. Her husband is in good health.Family History:Unknown.Physical Examination:Temperature: 36.7 ℃Pulse: 80/min Respiration: 20/min Blood pressure: 112/70mmHg Blood pressure(basic):109/64mmHg General condition:Natural good erect posture. Well developed. Moderate nourished. Natural facial expression. Clear and cooperative in mentality. Regular respirations. Height: 160cm. No jaundice or rashes. No cyanosis andbruises, no liver palm or spider angioma. The shape of her head is normal. The superficial lymph nodes were not enlarged. Her neck is Supple. The thyroid is not enlarged.Thoracic part:The trachea is in the midline. No jugular vein prominence or abnormal pulsation. Degree of expansion is equal bilaterally. Breath sounds are clear without pathological sounds or rales. Heart rate was 80bpm with a regular cardiac rhythm. No pathologic cardiac murmur at each valvular area.Abdominal part:Liver and spleen are not palpable. The shape is round. No uterine contraction. Fetal position: ROA. The fetal position can be heard on the left lower quadrant. FH:140/min, FM+, abdomen circumference:96cm, fundus of uterus: 33cm, fetus’s estimated weight: 3200g.Pelvis:IS:23cm, IC:26cm, EC:21cm, IT:8.5cmAnus&vagina: NoneCervix contain condition: undone, knee jerk reflex(+)Laboratory Findings and Special Procedures:US(2010-11-24):fetal position: ROA, BPD 92mm, HC 338mm, AC 342mm, FL 74mm, HL 64mm, Fetal maturity IIIa, amniotic fluid index 158mm.Diagnosis:1.Gestation ages:39+5weeks, G1P0, not in labor, fetal position:ROA.Signature:06300700117王畅。