产科英文病例

CASEMedicalNumber:**********GeneralinformationName:**Age:25yearsoldSex:FemaleRace:HanOccupation:othersNationality:ChinaMaritalstatus:MarriedAddress:Wuhan,HubeTel:*********Dateofadmission:Dec.27th,2015Dateofrecord:11am,Dec.27th,2015Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Thepatientwasfoundcessationofmenstruationfor36+2wandvaginalbleedingforoveroneweek.Presentillness:Thepatienthadregularmensespreviously.Thefirsttimewhenshewas14.Lasting4dayseverytimesanditscycleisabout30-45days.LMP:2015-4-17.UricHCGtestwaspositiveafter50daysofamenorrhea.On2015-6-10,hertype-BultrasonicrevealedIntrauterineearlypregnancy,correspondtogestationalweekof6weeks+.Accordingtotheearlyultrasonicresult,wecalculateEDCis2016-2-2.Thepatientdidnothaveobviousnauseaandvomitingofpregnancy(NVP)inearlystageofpregnancy.Fetalmovementswerefeltin4months’gestation.Shedidante-partumexaminationfortotallyseventimes,butdidnotdodown'sscreeningandTORCHscreening.OGTTshowedthatthelevelofherfastingbloodglucoseis5.17mmol/L,whilethelevelofpostprandialbloodsugarisnormal.Inthecourseofgestation,thepatientdidnotgetintouchwithanyradioactiverays,toxicantorpets.On2015-12-20,thepatientwenttolocalhospitalfortreatmentasaresultofalittlevaginalbleeding.Afteradmission,shewasgivenmagnesiumsulfateforfetusprotectionanddexamethasoneforpromotionoffetallungmaturity.whenherbleedingstationisundercontrol,shelefthospital.On2015-12-26,asaresultof“largeamountofvaginalbleeding,morethanmenstrualbloodvolume”,shewenttoCentralHospitalofXianningwithemergencyvisit.Afteradmission,shewasgivenRitodrineforfetusprotection.Andthenshewassenttoourhospitalforfurthertreatment.Untiltoday,thepatientisfoundcessationofmenstruationfor36+2w,andfurtheraccountinggestationalageis35weeksaccordingtotheultrasonic.Thereisstillsomedarkredvaginalbleeding.Whilethepatientdidnotfeelabdonimalpain,andtherewasnovaginaldischarge.Soshewasacceptedtoourhospitalandherdiagnosiswas“36+2weeksofgestation,Dangerousplacentaprevia”.Afteradmission,sheappearsclear,withagoodappetite,goodsleeping,andnormalurinationanddefecation.Herstrengthisalittlediminished,andtheweighthasphysiologicalchanges.PasthistoryHealthstatus:good.Operativehistory:Shereceivedcesareanoperationin2011.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninHubeiandalmostalwayslivedinWuhan.TherewasnoanyendemicdiseaseinWuhan.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas14.Lasting4dayseverytimesanditscycleisabout30-45days.LMP:2015-4-17.Obstetricalhistory:maritalage:22yearsold.Pregnacy4times,oncecesareandelivery.inducedabortion2times.Familyhistory:Herparentsarebothalive.PhysicalexaminationT:36.0℃P:76/minR:20/minBP:112/67mmHgGeneralappearance:Patientisa25yearsoldfemalewhoappearspleasant,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:76/min.Nobruits.Right(cm)RibinterspaceLeft(cm)2.5Ⅱ22.5Ⅲ43Ⅳ6Ⅴ8Theleftmid-clavicularlineis8.5cmawayfromfrontmidsternalline.Radialpulseisnormal.Abdomen:Inspection:Universialabdominalbulge.Dilatedveinsunobserved.Palpation:Soft.Liverandspleenisnotenlarged.Nontender.Murphy’ssignisnegative.Fordetailsseeobstetricexamination.Percussion:Noshiftingdullness.Theupperborderoftheliverisinthe5thintercostalspace.Ausculation:Bowlsoundclear.4/min.Spineandextremities:Severeedemainbothlowerextremities.Noclubbedfinger.Nodisorderofthemovementofaxialandappendicularbones.Reflex:Symmetri