第一篇：妇科英文病历
CASE
Medical Number: 756943 General information Name: Yue Jun-rong Age: Forty-two years old Sex: Female Race: Han Occupation: Unemployment Nationality: China Marital status: Married Address: Xiaochang county
of
Xiaogan city in Hubei.Tel: 4835963
Date of admission: Feb.27th, 2003 Date of record: 3pm, Feb.27th, 2003 Complainer of history: the patient herself
Reliability: Reliable Chief complaint: The patient was found “myoma of uterus” over two years ago and menometrorrhagia for 5 months.Present illness: In 1999, the patient was found “myoma of uterus” in a physical examination.But she had nothing uncomfortable and her catamenia was normal.She used some Chinese traditional medicine.About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 days.She felt no pain and the quantity was normal.She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.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 Hubei on July 16th, 1956 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 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examination
T 36.8℃, P 80/min, R 20/min, BP 120/80mmHg.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 Blood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/l Urine-Rt: SG 1.070 pH 6.0 B-ultrasound: 1.subserous myoma of uterus
2.position of loop is normal Hepatic function: Normal PT & APTT: Normal
Professional Examination Pudendum: Married type
Vagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth.Others: Normal
History summary
1.Patient was female, 45 years old 2.The patient was found “myoma of uterus” over two year ago and menometrorrhagia for 5 months..3.No special past history.4.Physical examination showed no abnormity in lung, heart and abdoman.Professional examination can been seen above.5.investigation information: see above
Impression: subserous myoma of uterus
Signature: He Lin(95-10033)
第二篇：妇科方面 护理病历
妇科护理病历
一、病人基本情况
科别：妇科 姓名：刘志玲 性别：女 年龄：45岁 婚姻：已婚 职业：干部 文化程度：大专 民族：汉 入院日期：2013-11-10 收集资料日期：2013-12-1 医疗诊断：异位妊娠 既往身体状况：
1.个人史：生于原籍，久居成都市彭州，无放射性物质及毒物接触史，无烟酒等不良嗜好。
2.家族史：父母体健，无遗传病史。心理社会状况：
1.精神状态：着装得体，无异常行为，思维、语言均正常，能够准确表达自身感觉，与医护沟通顺畅，情绪稍焦虑。
2.对健康与疾病的认识：对健康与疾病均无明确认识，难以承受疾病的痛苦，对疾
病存在恐惧，渴望健康，积极接受治疗。
3.人际关系：①平素与同事及家人关系融洽；②与医护人员关系良好，沟通正常；③与陪护人员及同室患者相处融洽。
4.应对能力：反应正常，能认清自己的角色，对治疗及护理无顾虑，积极配合治疗。5.价值观、信仰：价值观正确，无宗教信仰。6.人格类型：开放自然、独立、依赖。
二、病史
既往病史：患者有慢性妇科炎症2年，无高血压，糖尿病病史，无药物过敏史，无毒物药及疫区接触史。
三、体格检查
体温：36.8℃ 心率：92次/分 血压：135/80mmhg 身高：1.56m
体重：55Kg 1.皮肤、黏膜：全身皮肤黏膜无黄染，无出血点及皮疹，未见肝掌，蜘蛛痣淤点，淤斑。
2.淋巴结 ：全身浅表淋巴结未触及肿大。
3.头部及其器官：头颅及五官无畸形，颜面无浮肿，双侧眼睑结膜无苍白，巩膜无黄染，双侧瞳孔等圆等大，直径2.5mm，对光反射灵敏，鼻腔无异常分泌物。外耳道无异常分泌物，两侧鼻唇沟对称，唇无发绀，伸舌居中，口腔无溃疡，咽无充血，扁桃体无肿大，无脓性分泌物。
4.颈部：气管居中，甲状腺无肿大，无颈部静脉充盈、未闻及血管杂音。5.胸部：对称，未见皮疹，未见皮下气肿，胸骨无压痛，未触及皮下捻雪感，呼吸平顺，双侧胸廓扩张对称，双侧语颤对称。
6.肺：双肺叩诊是清音，双呼吸音清，未闻及干湿罗音。
7.腹部：输尿管行程无压痛，右肾区叩痛（+），移动性浊音（-），腹部叩诊肠鸣音正常，约5次/分。
8.脊柱四肢：脊柱、四肢无畸形，四肢肌力及肌张力正常，双下肢无水肿，双膝膝关节无积液，无压痛，生理反射存在，病理反射无未引出，活动未见明显受限，无静脉曲张。
9.神经系统：意识状态清晰，精神状态定向力正常，理解力正常，情绪正常。感觉系统，运动系统检查正常，生理反射存在，病理反射未引出，脑膜刺激征阴性。
四、实验室及特殊检查
（1）后穹隆穿刺：抽出2ml不凝血。
（2）尿HCG+ 尿比重>=1.030 尿pH5.0 尿白细胞Ca15Cells/ul 尿亚硝酸盐negative 尿蛋白定性negative 葡萄糖negative 尿酮体>=7.8mmol/L尿胆原3.2umol/L尿胆红素small umol/L 尿红细胞small/uL
（3）血白细胞8.1×109/L 淋巴细胞百分比24.2% 中间细胞百分比2.5% 中性粒细胞百分比73.3% 淋巴细胞绝对值1.9×109/L中间细胞绝对值0.2×109/L中性粒细胞绝对值6.0×109/L 红细胞3.37×1012/L 血红蛋白测定109G/L 红细胞压积29.5% 血小板计数221×109/L
（4）特殊检查：B超声：子宫5.2×5.1 ×3.8cm，内膜厚约0.8cm，肌层回声尚匀，右卵巢2.7×2.0cm，左附件区可探及6.3×3.6cm的混合回声，内见直径1.7cm的强回声。子宫后方可见6.7×5.5×3.5cm的游离暗区，内可见数个分隔。
五、病历摘要
患者停经45天，下腹部 轻度疼痛，阴道有少量出血，尿HCG阳性，入院诊断。经入院检查，查体有腹膜刺激症状，下腹压痛+，反跳痛+移浊±，宫颈明显举痛，并似可及界不清的包块，直径约4～5cm后穹隆穿刺证实有血。尿HCG+，血β-HCG 2122.3miu/L等，确诊为以为异位妊娠（宫外孕）。予以口服止痛药物，进行急诊手术治疗。
六、护理诊断及相应护理措施
2013.11.10护理诊断：疼痛与卵囊扩大有关。护理措施：
（1）安抚患者紧张情绪，绝对卧床，避免做增加腹压的动作。（2）心电监护监测观，注意观察心率，血压，尿量变化等。（3）阴道出血，剧烈腹痛，脉搏快而弱，应警惕有内出血或休克。（4）遵医嘱给予5%葡萄糖500ml静点给药。2013.11.11 1.术前护理诊断：焦虑与恐惧及痛苦有关。护理措施：
（1）安抚患者紧张情绪，耐心热情的设法消除其对手术的顾虑以及恐惧。（2）给与患者心理安慰以分散注意力减轻患者疼痛；必要时遵医嘱给予适量的止痛剂。
（3）做好剖宫手术的准备工作。
2.手术护理诊断：疼痛、出血及并发症与手术有关。护理措施：
（1）对患者进行相应的心理护理，分散注意力减轻患者疼痛；必要时遵医嘱给予适量的止痛剂。
（2）配合医生进行手术，予以相应的体位护理、疼痛护理及并发症的预防护理。
3.术后护理诊断：疼痛与手术创口有关。护理措施：
（1）医嘱给予心电监护24小时，严密观察呼吸、心率、血压等生命体征的变化。
（2）持续氧气吸入，禁食水静脉留置针通畅，去枕平卧位休息。
（3）观察术后有无出血情况，如伤口敷料有无渗出，阴道有无出血；观察有无血压下降脉搏快而弱，口唇面色苍白，烦躁不安，出冷汗等内出血征象，应及时通知医生。
2013.11.12护理诊断：焦虑与知识缺乏，对异位妊娠及剖宫术缺乏认识相关。护理措施：
（1）了解患者的思想情况及对自身疾病的认识程度，做针对性的宣教。向其介绍宫外孕的发病原因、手术步骤及治疗方案，讲述好转病例增加患者对疾病好转的信心。
（2）予以常规输液护理，针对疼痛等并发症进行对症处理。2013.11.13护理诊断：便秘，腹痛与手术有关。护理措施：
（1）消除或减少引起便秘的因素，根据病情给予易消化，富含维生素的饮食及水果，腹部按摩，增加胃肠蠕动。
（2）嘱患者排便时避免太用力或者屏气，用力排便会影响腹部创口愈合或加剧疼痛。
（3）分散注意力减轻患者疼痛；必要时遵医嘱给予适量的止痛剂。2013.11.14护理诊断：综合检查，出院诊断 护理措施：
（1）常规检查各项生命指征，B超检查子宫恢复情况。
（2）询问患者的感觉，有无不适，检查创口及出血情况。与其沟通了解患者的患者神志状态、食欲等，并予以相应指导。
（3）予以出院指导，告知患者出院时间。
七、出院指导：
1、饮食指导：出院后给予患者高蛋白，高热量，高维生素且易消化的饮食；少时生冷油腻的食物，多食用水果、蔬菜等高维生素食物，均衡营养，加速康复。2.工作及活动指导：出院后卧床休息7日，不可坐浴。7日后可参加全体力劳动外的工作，避免接触冷水，一个月后可正常工作；术后禁止性生活一个月，半年内应采取避孕措施，防止再次妊娠。养成良好的卫生习惯，勤洗浴勤换衣，稳定性伴侣。若伴有盆腔炎、阴道炎等妇科疾病应彻底治疗。
3.疾病预防指导：出院后按医嘱服用抗生素，预防术后感染。若出现腰酸、下腹部等症状时，及时进行B超检查，及时治疗。
4.妊娠指导：有异位妊娠病史的患者，再次异位妊娠的可能性增加，对于还有生育要求的患者予以指导，妊娠前需通过B超检查对子宫的恢复程度进行评估，恢复良好后方可进行妊娠，防止子宫破裂的并发症的发生；怀孕前对输卵管通畅度进行检查，以减少再次异位妊娠的发生率；因输卵管妊娠患者再次发生宫外孕的几率为10%，不孕率高达50-60%。所以再次妊娠时，应及时就诊，不要轻易终止妊娠。
八、讨 论
护理病历不仅能够反映整个护理过程，而且为临床治疗及护理操作提供参考数据，对提高护理质量，改善患者生活质量，均具有重要的价值。护理病历要求运用护理程序护理患者，要求有系统、完整、能反映护理全过程的记录，包括有关病人的资料、护理诊断、护理目标、护理计划及效果评价，构成护理病历。书写要求详细记录、突出重点、主次分明、符合逻辑、文字清晰及正确应用医学术语。
此病例为妇科异位妊娠病历，根据医嘱及患者的疾病、身体及心理特点，制订了相应的护理计划，并按计划实施，保证了手术的疗效，赢得了患者的主动配合，患者顺利完成治疗，心理及精神状态良好，得到了患者的好评。综合异位妊娠护理的临床体会，主要有以下几点：
（1）常规护理：患者围手术期予以绝对卧床休息，按常规建立静脉通道，并针对并发症给予相应药物及补液护理。
（2）健康宣教：患者因疼痛、惧怕手术等常出现紧张、焦虑等不良心理，影响手术的依从性及疗效。以此术前及术后需就手术的操作、疗效、注意事项及疗效等相关内容进行健康宣教。
（3）心理护理：针对患者不良心理予以相应的心理护理，使患者自愿接受治疗，消除不良心理，从而确保手术的疗效及依从性。
（4）出院指导：就饮食、工作、活动、疾病预防、妊娠等内容进行指导。尤其是再次妊娠指导尤为重要。因异位妊娠病史的患者，再次异位妊娠的可能性增加，再次妊娠前需通过B超检查对子宫的恢复程度进行评估，恢复良好后方可进行妊娠，防止子宫破裂的并发症的发生；怀孕前对输卵管通畅度进行检查，以减少再次异位妊娠的发生率。以提高患者再次妊娠的安全性。
综合所述，在异位妊娠护理过程中应针对患者具体情况，做好健康宣教、心理护理及常规护理，护理过程中应坚持“以患者为中心”，采用规范的语言及肢体语言，熟练的操作，按要求完成护理操作。从而确保手术疗效，提高护理的依从性。由此，证实护理操作具有重要的价值。
第三篇：妇科门诊病历书写
姓名：罗珊 性别：女 出生日期：1975年10月25日 家庭地址：******* 过敏史：未发现
时间：2009年11月25日 主诉：停经38天
现病史：lmp：09.10.16 停经38天 自测尿液妊娠试验（+）既往史：体健
月经史：14 4-5/28-30 量中等 痛经（+）末次月经：09.10.16 婚育史：1-0-2-1 末孕药流 工具避孕 家族史：无特殊 体健：外阴：已婚式
阴道：畅，分泌物量中，乳白
宫颈：颈光，轻度糜烂，宫口可见一赘生物约绿豆大
宫体：前位，质中，举痛（-）
双附件未及
初步诊断：早孕
处理：B超（孕80天左右）
腹痛、出血随诊
陈**
09.12.25 病史同前 lmp：09.10.16 停经68天 阴道瘙痒 尿妊（+）PE:外阴：（-)阴道：畅，分泌物量少，略黄
宫颈：轻糜，宫壁粗糙，肥大 宫体：前位，质中，举痛（-）
双附件未及
白带Rt：细35% 三度 6：4 IMP:早孕
阴道炎 R/:克霉唑阴道片栓塞 qd*7 B超
腹痛、出血随诊
第四篇：妇科病历书写要点
妇科病历书写要点
妇科病历
1．现病史
（1）闭经：以往月经情况，有无伴发症状及服用避孕药或其他激素史。
（2）阴道流血：与月经的关系、数量及持续时间。
（3）腹痛：发病时间、部位、性质、与月经的关系、以往有无类似发作史。
（4）腹部包块：部位、增长速度，有无疼痛或压痛，有无对邻近脏器的压迫症状等。
（5）白带：量、性质、持续时间。
2．婚姻史
结婚年龄、丈夫健康情况，不孕症患者应询问性生活史及丈夫精液检查情况。
3．月经史
应较为详细地记录。
4．生育史
胎次、产次、分娩情况、末次妊娠时间。
5．体格检查
（1）腹部检查：形态，有无肌紧张、压痛、反跳痛（尤其是下腹），有无肿块（部位、大小、形状、质地、活动度、压痛）及移动性浊音。
（2）妇科检查：
外阴：已产式还是未产式，发育、阴毛、*、前庭大腺、会阴、尿道口情况，有无赘生物、畸形。阴道：发育、粘膜情况，有无畸形、分泌物及出血（量、色、气味），白带及其性状。
宫颈：大小、质地，是否光滑，有无裂痕、糜烂（轻、中、重度）、外翻、赘生物、举痛。宫体：大小、形状、位置、质地、活动度、压痛、畸形。
附件：压痛、肿块大小、质地、位置、活动度，左右两侧分别查明并记录。
第五篇：口腔科英文病历
Oral and Maxillofacial Surgery Complete Medical History
（Zhang te）
Medical Number: 182786 General information Name: Tao lili Age: Forty eight Sex: Female Race: Han Occupation: worker Nationality: China Marital status: Married Address:NO.138,mawangdui
Rvenue,changsha, Hunan.Tel: 84722500
Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself
Reliability: Reliable
Chief complaint: lower incisors gingivae mass found for more than 3 month.Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae.After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache.the patient didn’t pay attention it.Then the mass became more and more bigger, so the patient 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.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
Oral mucous membrane was smooth, and of no ulcer or erosion.Tongue was in midline.Pharynx was not congestive.Tonsils were not enlarged.Patients with poor oral hygiene has much dental calculus.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but not bleed.It can not be moved and its surface is smooth.Corresponding superficial lymph nodes don’t enlarge.Impression: Epulis
Signature: Zhang te
Hospital course record for the first time 2013-6-20 8:50
一、Characteristics of cases：
1.Clinical presentation:Patient was a worker , female, 48 years old.2.lower incisors gingivae mass found for more than 3 month.3.No special past history.4.Physical examination showed no abnormity in lung, heart and abdoman.Information about her oral can be seen above.5.Shorting of investigation information.6.Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60.二、Examination to discuss diagnostic basis：1.lower incisors gingivae mass found for more than 3 month。2.She did not get fever ,dizziness, vertigo and headache.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but not bleed.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but not bleed.differential diagnosis：Gingival carcinoma：Except fast growth, it can appear local canker, pain, involving related to teeth.ADMITTING DIAGNOSIS:Epulis
三、Case classification：A
四、Treatment plan：1.To improve the routine inspection.2.Whole mouth clean governance.3.Optional operation.Xu yuguo
Hospital records 2013-6-21 The patient was hospitalized on this morning.with suddenly found a small mass on lower incisors gingivae 3 month ago.transparent mild redness, lining color is normal, Patients usually in good health.Blood, urine, dung routine has been sent, liver and kidney function checklist to fill in, check the doctor's advice already open.Pathological biopsy for the diseased tissue has been sent.Xu yuguo 2013-6-23 This morning Pro.zhang visits, the diagnosis and treatment of put forward the following opinions:Pathological biopsy result has shown Epulis.All investigation is normal.According to the clinical manifestations of it ,this disease The disease can be diagnosed with Epulis.Gum tumor resection Can be imposed immediately.Preoperative should be whole mouth clean governance.surgery will be done at eight on tomorrow morning.Zhang te/ Xu yuguo
2013-6-24 Preoperative SUMMARY Patient was a worker , female, 48 years old.lower incisors gingivae mass found for more than 3 month.No special past history.Physical examination showed no abnormity in lung, heart and abdoman.Information about her oral can be seen above.All investigation is normal.whole teeth have been cleaned.Surgical treatment plan:(1)pastoperative biopsy to determine the tumor nature;(2)Complete removal of the tumor and spread of the periodontal membrane, teeth and gums.(3)a mandibular defect should still depending on the nature of the tumor and then make a decision whether to immediately bone graft, but should be ready to immediately bone graft.(4)preoperative for teeth cleaning and use of antibiotics.Xu yuguo 2013-6-25 8:15
Operation records
Make Routine local anesthesia on the patient supine, disinfection and shop towels according to Maxillofacial surgery routine.lump completely and spread of the periodontal membrane, and gums been removed with electricity knife.hydrogen peroxide and saline flush incision.Mass was sent to Pathological biopsy.The patient went back the ward safetyly at 9:30 , The surgery was over.Zhang te
2013-6-26
Pastoperative records
T 36.5℃, P 80/min, R 23/min, BP 100/60mmHg.Patients feel the wound and teeth pain is severe, the wound near swollen gums, jaw was covered with a little fake.Continue to Analgesic, anti-inflammatory.Pay attention to maintain oral hygiene.Patients require to dischange tomorrow, he Would be approved to agree with.Zhang te
DISCHARGE RECORD
DATE OF ADMISSION: Jun 20st, 2013 DATE OF DISCHARGE: Jun 26st, 2013 Number of days in hospital:6 Days
ADMITTING DIAGNOSIS: Epulis
BRIEF HISTORY PATIENT name :Tao lili , AGE: 48 3 month ago, the patient suddenly found a small mass on lower incisors gingivae.After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache.the patient didn’t pay attention it.Then the mass became more and more bigger.REVIEW OF SYSTEM She has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORY She has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMILY HISTORY She has no family history of cardiovascular, respiratary and gastrointestinal diseases.PHYSICAL EXAMINATION Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60.General: Plump girl in no apparent distress.HEENT: She has no scalp lesions.Her pupils are equally round and reactive to light and accommodation.Extraocular movements are intact.Sclerae are anicteric.Oropharynx is clear.There is no thyromegaly.There is no cervical or supraclvicular lymphadenopathy.Cardiovascular: Regular rate and rhythm, normal S1, S2.Chest: Clear to auscultation bilateral.Abdomen: Bowel sounds present, no hepatosplenomagaly.Extremities: There is no cyanosis, clubbing or edema.Neurologic: Cranial nerves II-XII are intact.Motor examination is 5/5 in the bilateral upper and lower extremities.Sensory, cerebellar and gait are normal.HOSPITAL COURSE The patient was admitted.The patient was resect the gums tumor and improved.The patient was discharged in stable condition.DISCHARGE DIAGNOSIS Epulis
DISCHANGE INSTRCTIONS: To pay attention to rest, strengthen nutrition, keep the anti-inflammatory for three days.To maintain oral hygiene.To review on a regular basis.PROGNOSIS Good.No medications needed after discharge.The patient is to follow up with Dr.xu in one week.Zhang te/ Xu yuguo
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