口腔科英文病历.docx
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口腔科英文病历
口腔科英文病历
OralandMaxillofacialSurgeryCompleteMedicalHistory
(Zhangte)
MedicalNumber:
182786
Generalinformation
Name:
Taolili
Age:
Fortyeight
Sex:
Female
Race:
Han
Occupation:
worker
Nationality:
China
Maritalstatus:
Married
Address:
NO.138,mawangduiRvenue,changsha,Hunan.
Tel:
84722500
Dateofadmission:
Jun20st,2013
Dateofrecord:
11Am,Jun20st,2013
Complainerofhistory:
thepatientherself
Reliability:
Reliable
Chiefcomplaint:
lowerincisorsgingivaemassfoundformorethan3month.
Presentillness:
3monthago,thepatientsuddenlyfoundasmallmassonlowerincisorsgingivae.Aftertouchingit,shefoundamasstendness,Shedidnotgetfever,dizziness,vertigoandheadache.thepatientdidn’tpayattentionit.Thenthemassbecamemoreandmorebigger,sothepatientshecametoourhospitalandaskedforanoperation.
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.
Obstetricalhistory:
Pregnacy3times,oncenatureproduction,abortiontwice.
Contraceptivehistory:
Notclear.
Familyhistory:
Hisparentshavebothdied.
Physicalexamination
T36.4℃,P80/min,R20/min,BP90/60mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.
Head
Cranium:
Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.
Ear:
Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.
Nose:
Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.
Eye:
Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.
Neck:
Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.
Chest
Chestwall:
Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.
Thorax:
Symmetricbilaterally.Nodeformities.
Breast:
Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.
Lungs:
Respiratorymovementwasbilaterallysymmetricwiththefrequencyof20/min.Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.
Heart:
Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate80/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.
Abdomen:
Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Therewasnottendernessandreboundtendernessonabdomenorrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.
Extremities:
Noarticularswelling.Freemovementsofalllimbs.
Neuralsystem:
Physiologicalreflexeswereexistentwithoutanypathologicalones.
Genitourinarysystem:
Notexamed.
Rectum:
notexaned
Investigation
No.
ProfessionalExamination
Oralmucousmembranewassmooth,andofnoulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotenlarged.Patientswithpoororalhygienehasmuchdentalcalculus.Thereareaabout2*2*1.5cmmassonlowerincisors(33-41)gingivae.Itistenderbutnotbleed.Itcannotbemovedanditssurfaceissmooth.Correspondingsuperficiallymphnodesdon’tenlarge.
Impression:
Epulis
Signature:
Zhangte
Hospitalcourserecordforthefirsttime
2013-6-208:
50
1、Characteristicsofcases:
1.Clinicalpresentation:
Patientwasaworker,female,48yearsold.
2.lowerincisorsgingivaemassfoundformorethan3month.
3.Nospecialpasthistory.
4.Physicalexaminationshowednoabnormityinlung,heartandabdoman.Informationaboutheroralcanbeseenabove.
5.Shortingofinvestigationinformation.
6.Temperatureis36.5℃,pulse80,respirations20,bloodpressure90/60.
二、Examinationtodiscuss
diagnosticbasis:
1.lowerincisorsgingivaemassfoundformorethan3month。
2.Shedidnotgetfever,dizziness,vertigoandheadache.Thereareaabout2*2*1.5cmmassonlowerincisors(33-41)gingivae.Itistenderbutnotbleed.Thereareaabout2*2*1.5cmmassonlowerincisors(33-41)gingivae.Itistenderbutnotbleed.
differentialdiagnosis:
Gingivalcarcinoma:
Exceptfastgrowth,itcanappearlocalcanker,pain,involvingrelatedtoteeth.
ADMITTINGDIAGNOSIS:
Epulis
三、Caseclassification:
A
四、Treatmentplan:
1.Toimprovetheroutineinspection.2.Wholemouthcleangovernance.3.Optionaloperation.
Xuyuguo
Hospitalrecords
2013-6-21
Thepatientwashospitalizedonthismorning.withsuddenlyfoundasmallmassonlowerincisorsgingivae3monthago.transparentmildredness,liningcolorisnormal,Patientsusuallyingoodhealth.Blood,urine,dungroutinehasbeensent,liverandkidneyfunctionchecklisttofillin,checkthedoctor'sadvicealreadyopen.Pathologicalbiopsyforthediseasedtissuehasbeensent.
Xuyuguo
2013-6-23
ThismorningPro.zhangvisits,thediagnosisandtreatmentofputforwardthefollowingopinions:
PathologicalbiopsyresulthasshownEpulis.Allinvestigationisnormal.Accordingtotheclinicalmanifestationsofit,thisdiseaseThediseasecanbediagnosedwithEpulis.GumtumorresectionCanbeimposedimmediately.Preoperativeshouldbewholemouthcleangovernance.surgerywillbedoneateightontomorrowmorning.
Zhangte/Xuyuguo
2013-6-24
PreoperativeSUMMARY
Patientwasaworker,female,48yearsold.lowerincisorsgingivaemassfoundformorethan3month.Nospecialpasthistory.Physicalexaminationshowednoabnormityinlung,heartandabdoman.Informationaboutheroralcanbeseenabove.Allinvestigationisnormal.wholeteethhavebeencleaned.Surgicaltreatmentplan:
(1)pastoperativebiopsytodeterminethetumornature;
(2)Completeremovalofthetumorandspreadoftheperiodontalmembrane,teethandgums.(3)amandibulardefectshouldstilldependingonthenatureofthetumorandthenmakeadecisionwhethertoimmediatelybonegraft,butshouldbereadytoimmediatelybonegraft.(4)preoperativeforteethcleaninganduseofantibiotics.
Xuyuguo
2013-6-258:
15
Operationrecords
MakeRoutinelocalanesthesiaonthepatientsupine,disinfectionandshoptowelsaccordingtoMaxillofacialsurgeryroutine.lumpcompletelyandspreadoftheperiodontalmembrane,andgumsbeenremovedwithelectricityknife.hydrogenperoxideandsalineflushincision.MasswassenttoPathologicalbiopsy.Thepatientwentbackthewardsafetylyat9:
30,Thesurgerywasover.
Zhangte
2013-6-26
Pastoperativerecords
T36.5℃,P80/min,R23/min,BP100/60mmHg.Patientsfeelthewoundandteethpainissevere,thewoundnearswollengums,jawwascoveredwithalittlefake.ContinuetoAnalgesic,anti-inflammatory.Payattentiontomaintainoralhygiene.Patientsrequiretodischangetomorrow,heWouldbeapprovedtoagreewith.
Zhangte
DISCHARGERECORD
DATEOFADMISSION:
Jun20st,2013
DATEOFDISCHARGE:
Jun26st,2013
Numberofdaysinhospital:
6Days
ADMITTINGDIAGNOSIS:
Epulis
BRIEFHISTORY
PATIENTname:
Taolili,AGE:
48
3monthago,thepatientsuddenlyfoundasmallmassonlowerincisorsgingivae.Aftertouchingit,shefoundamasstendness,Shedidnotgetfever,dizziness,vertigoandheadache.thepatientdidn’tpayattentionit.Thenthemassbecamemoreandmorebigger.
REVIEWOFSYSTEM
Shehashadnoheadache,fever,chills,diarrhea,chestpain,palpitations,dyspnea,cough,hemoptysis,dysuria,hematuriaorankleedema.
PASTMEDICALHISTORY
Shehashadnoprevioussurgery,accidentsorchildhoodillness.
SOCIALHISTORY:
Shehasnohistoryofexcessivealcoholortobaccouse.
FAMILYHISTORY
Shehasnofamilyhistoryofcardiovascular,respirataryandgastrointestinaldiseases.
PHYSICALEXAMINATION
Temperatureis36.5℃,pulse80,respirations20,bloodpressure90/60.General:
Plumpgirlinnoapparentdistress.HEENT:
Shehasnoscalplesions.Herpupilsareequallyroundandreactivetol