外科英文病历模板

外科英文病历模板

CASE

Medical Number: 682786

General information

Name: Wang Runzhen

Age: Forty three

Sex: Female

Race: Han

Occupation: Teacher

Nationality: China

Marital status: Married

Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500 Date of admission: Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable

Chief complaint: Right breast mass found for more than half a month.

Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then 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.

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