妇产科英文病历

InpatientHistoryName:YaliZhouSex:FemaleAge:38yearWard:No.8Bed:No.816Maritalstatus:MarriedBirthplace:ShanghaiNationality:HanProvider:Patient,reliable.Recorddate:2005-12-13G&OHistory:GW:30+5weeks,G2P0,LMP:2005-5-10;EDC:2006-2-17ChiefComplaint:G2P0,GW:30+5weeks.Thispatientpresentshypertensionfor3months,andsystemicedemafor2weeks.HistoryofPresentillness:Thepatienthadregularmensespreviously.LMP:2005-5-10;EDC:2006-2-17.UricHcGtestwaspositiveafter40daysofamenorrhea.Fetalmovementswerefeltin4months’gestation.In12+2weeks’gestation,thepatient’sbloodpressurewasfound160/90mmHgwhenshecompletedherfirstante-partumexaminationinHospitalofWomenandChildren’sHealthinHuangpuDistrict.Therewasnosymptomsatthattime,andshedidn’ttakeanytreatment.Halfamonthago,shepresentededemaonboththelowerextremities,whichexpandedtothewholebodygradually.ShecametoourhospitalonDec,5thandtookhersencondante-partumexamination.Thebpwas200/160mmHg,anduricprotein(++)ondipsticktest.Shehasoccasionalheadaches,butnoepigastricpain,novisualdisturbances,nooliguria,nonauseaorvomiting,nothoracicpain.Shewasadmittedon2005-12-6.Afteradmission,sheappearsclear,withagoodappetite,goodsleeping,andnormalurinationanddefecation.Pasthistory:Patientdenieshistoryofhepatitisandtuberculosis.Nohistoryofallergies.Vaccinatedregularly.Pastmedicalhistoryisunremarkable.Surgicalhistorydenied.Nohistoryofseveretraumaandtransfusion.Reviewofsystems:Respiratorysystem:Nohistoryofchroniccoughorbreathlessness.Nohemoptysisordyspnea.Cardiovascularsystem:Noprecordialpain.Nopalpation.Nosyncope.Fordetailsseepresenthistory.Gastroentestinalsystem:Nohistoryofchronicabdominalpainanddiarrhea;Nonauseaorvomiting;Nohematemesisandbloodstool.Endocrinicsystem:Nopolydipsiaorpolyphasiaorpolyuria.Nosuddenchangeofcharacterandintelligence.Hematologicsystem:Nobruisesorabnormalhemorrhage.Norecurrentoralulcerandgingivalbleeding.Genitourinarysystem:Nodecreasedlibido;Novaginaldrynessorvaginalbleeding;HistoryofSTDdenied;Nourinaryfrequency.Noprecipitanturinationordysuria.Nohematuriaorproteinuria.Neuropsychiatricsystem:Noconvulsionoranesthesia.Noheadaches.Noabnormalorientation.Nodeteriorationofmemoryorintelligence.Locomotorsystem:Noarthralgia,nomuscularatrophiesordystrophies.PersonalHistory:BornandgrownupinShanghai.Patientdeniedhistoryoftobaccooralcoholuse.MaritalandChildbearinghistory:Married.0-0-1-0;Shehadanabortionin3months’gestationinDec.,2004.Birthcontrolhasbeeninstructed.Familyhistory:Thepatient’sMotherandasistersufferedfromhypertension.NofamilyhistoryofDMorstroke.Nofamilyhistoryofnervousormentaldiseases.PhysicalExaminationT:37℃P:89/minR:20/minBP:180/120mmHgGeneralappearance:Patientisa38yearsoldfemalewhoappearspleasant,innoapperantdistress,givenherage,welldevelopedandwellnourished.Orientedtoperson,placeandtime.Lymphnodes:Notenlarged.Skin:Nojaundiceorrashes.Nocyanosisandbruises.Noedema.Head:Skullandscalpnormal.Notenderness.Nolossofhair.Eyes:Noedemaineyelids,noptosis,noconjunctivalcongestion.Widthofpalpebralfissuresisnormal.Nojaundice.Pupil’ssizeandshapeisnormal.Cornealisclear.Noexophthalmos.Ears:Auditoryacuityisexcellent.Noearpurulentdischarge.Nose:Shapeisnormal.Noobstruction.Nodeviationofnasalseptum.Mouth:Nolipsherpes.Nocyanosis.Nogumspyorrheaandbleeding.Notonguedeviation.Tonsilsnotenlarged.Neck:Herneckissoft.Tracheaismidline.Nothyroidabnormalitywasfound.Neckveinwasnotdistended.Chest:Contourisnormal.Nosternumtenderness.Thebreastsarebilaterallysymmetrical.Notendernessandmass.Lung:Inspection:Respirationregular.Degreeofexpansionissymmetry.Plapation:Tactilefremitussymmetrical.Percussion:extensiveresonancetopercussion.Ausculation:Cleartoausculationwithnorubsnoted.Heart:Inspection:Noabnormalpulsationorretraction.Plapation:Theapexbeatcanbefeltinthe5thintercostalspace1cminsideoftheleftmid-clavicularline.Percussion:Theborderofcardiacisnotenlarged.Ausculation:Theheartsoundswereofgoodqualityandtherhythmwasregular.Heartrate:96/min.Nobruits.Right(cm)RibinterspaceLeft(cm)2.5Ⅱ22.5Ⅲ43Ⅳ6Ⅴ8Theleftmid-clavicularlineis9cmawayfromfrontmidsternalline.Radialpulseisnormal.Abdomen:Inspection:Universialabdominalbulge.Dilatedveinsobserved.Palpation:Soft.Liverandspleenisnotenlarged.Nontender.Murphy’ssignisnegative.Fordetailsseeobstetricexamination.Percussion:Noshiftingdullness.Theupperborderoftheliverisinthe5thintercostalspace.Ausculation:Bowlsoundclear.4/min.Spineandextremities:Severeedemainbothlowerextremities.Noclubbedfinger.Nodisorderofthemovementofaxialandappendicularbones.Reflex:Symmetrical,equalwithoutpathologicalresponses.BabinskisignandKernigsignandhoffmannsignareallnegative.ObstetricexaminationPatientappearspleasant,givenherage,welldevelopedandwellnourished.Nojaundice.Noenlargedlymphnodes.Fetus:Abdominalgirth:93cm;heightoffundus:29cm;estimatedfetalweight:1600g;fetalposition:LOA;pointoffetalhearttone:;fetalheartrate:148/min;FM:active.Pelvis:24-17-19-9cm.Anorectalexamination:fetalpresentation:N/A;sincipitalpresentation:N/A;fetalmembrane:notruptured.Amnioticfluid:N/A;Flexionofknee:active.LaboratoryandspecialexaminationDec.6th,BloodRt:Hb:121g