第一篇：婦科英文病歷

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：婦科方面 護(hù)理病歷

婦科護(hù)理病歷

一、病人基本情況

科別：婦科 姓名：劉志玲 性別：女 年齡：45歲 婚姻：已婚 職業(yè)：干部 文化程度：大專 民族：漢 入院日期：2013-11-10 收集資料日期：2013-12-1 醫(yī)療診斷：異位妊娠 既往身體狀況：

1.個(gè)人史：生于原籍，久居成都市彭州，無放射性物質(zhì)及毒物接觸史，無煙酒等不良嗜好。

2.家族史：父母體健，無遺傳病史。心理社會(huì)狀況：

1.精神狀態(tài)：著裝得體，無異常行為，思維、語言均正常，能夠準(zhǔn)確表達(dá)自身感覺，與醫(yī)護(hù)溝通順暢，情緒稍焦慮。

2.對(duì)健康與疾病的認(rèn)識(shí)：對(duì)健康與疾病均無明確認(rèn)識(shí)，難以承受疾病的痛苦，對(duì)疾

病存在恐懼，渴望健康，積極接受治療。

3.人際關(guān)系：①平素與同事及家人關(guān)系融洽；②與醫(yī)護(hù)人員關(guān)系良好，溝通正常；③與陪護(hù)人員及同室患者相處融洽。

4.應(yīng)對(duì)能力：反應(yīng)正常，能認(rèn)清自己的角色，對(duì)治療及護(hù)理無顧慮，積極配合治療。5.價(jià)值觀、信仰：價(jià)值觀正確，無宗教信仰。6.人格類型：開放自然、獨(dú)立、依賴。

二、病史

既往病史：患者有慢性婦科炎癥2年，無高血壓，糖尿病病史，無藥物過敏史，無毒物藥及疫區(qū)接觸史。

三、體格檢查

體溫：36.8℃ 心率：92次/分 血壓：135/80mmhg 身高：1.56m

體重：55Kg 1.皮膚、黏膜：全身皮膚黏膜無黃染，無出血點(diǎn)及皮疹，未見肝掌，蜘蛛痣淤點(diǎn)，淤斑。

2.淋巴結(jié) ：全身淺表淋巴結(jié)未觸及腫大。

3.頭部及其器官：頭顱及五官無畸形，顏面無浮腫，雙側(cè)眼瞼結(jié)膜無蒼白，鞏膜無黃染，雙側(cè)瞳孔等圓等大，直徑2.5mm，對(duì)光反射靈敏，鼻腔無異常分泌物。外耳道無異常分泌物，兩側(cè)鼻唇溝對(duì)稱，唇無發(fā)紺，伸舌居中，口腔無潰瘍，咽無充血，扁桃體無腫大，無膿性分泌物。

4.頸部：氣管居中，甲狀腺無腫大，無頸部靜脈充盈、未聞及血管雜音。5.胸部：對(duì)稱，未見皮疹，未見皮下氣腫，胸骨無壓痛，未觸及皮下捻雪感，呼吸平順，雙側(cè)胸廓擴(kuò)張對(duì)稱，雙側(cè)語顫對(duì)稱。

6.肺：雙肺叩診是清音，雙呼吸音清，未聞及干濕羅音。

7.腹部：輸尿管行程無壓痛，右腎區(qū)叩痛（+），移動(dòng)性濁音（-），腹部叩診腸鳴音正常，約5次/分。

8.脊柱四肢：脊柱、四肢無畸形，四肢肌力及肌張力正常，雙下肢無水腫，雙膝膝關(guān)節(jié)無積液，無壓痛，生理反射存在，病理反射無未引出，活動(dòng)未見明顯受限，無靜脈曲張。

9.神經(jīng)系統(tǒng)：意識(shí)狀態(tài)清晰，精神狀態(tài)定向力正常，理解力正常，情緒正常。感覺系統(tǒng)，運(yùn)動(dòng)系統(tǒng)檢查正常，生理反射存在，病理反射未引出，腦膜刺激征陰性。

四、實(shí)驗(yàn)室及特殊檢查

（1）后穹隆穿刺：抽出2ml不凝血。

（2）尿HCG+ 尿比重>=1.030 尿pH5.0 尿白細(xì)胞Ca15Cells/ul 尿亞硝酸鹽negative 尿蛋白定性negative 葡萄糖negative 尿酮體>=7.8mmol/L尿膽原3.2umol/L尿膽紅素small umol/L 尿紅細(xì)胞small/uL

（3）血白細(xì)胞8.1×109/L 淋巴細(xì)胞百分比24.2% 中間細(xì)胞百分比2.5% 中性粒細(xì)胞百分比73.3% 淋巴細(xì)胞絕對(duì)值1.9×109/L中間細(xì)胞絕對(duì)值0.2×109/L中性粒細(xì)胞絕對(duì)值6.0×109/L 紅細(xì)胞3.37×1012/L 血紅蛋白測(cè)定109G/L 紅細(xì)胞壓積29.5% 血小板計(jì)數(shù)221×109/L

（4）特殊檢查：B超聲：子宮5.2×5.1 ×3.8cm，內(nèi)膜厚約0.8cm，肌層回聲尚勻，右卵巢2.7×2.0cm，左附件區(qū)可探及6.3×3.6cm的混合回聲，內(nèi)見直徑1.7cm的強(qiáng)回聲。子宮后方可見6.7×5.5×3.5cm的游離暗區(qū)，內(nèi)可見數(shù)個(gè)分隔。

五、病歷摘要

患者停經(jīng)45天，下腹部 輕度疼痛，陰道有少量出血，尿HCG陽性，入院診斷。經(jīng)入院檢查，查體有腹膜刺激癥狀，下腹壓痛+，反跳痛+移濁±，宮頸明顯舉痛，并似可及界不清的包塊，直徑約4～5cm后穹隆穿刺證實(shí)有血。尿HCG+，血β-HCG 2122.3miu/L等，確診為以為異位妊娠（宮外孕）。予以口服止痛藥物，進(jìn)行急診手術(shù)治療。

六、護(hù)理診斷及相應(yīng)護(hù)理措施

2013.11.10護(hù)理診斷：疼痛與卵囊擴(kuò)大有關(guān)。護(hù)理措施：

（1）安撫患者緊張情緒，絕對(duì)臥床，避免做增加腹壓的動(dòng)作。（2）心電監(jiān)護(hù)監(jiān)測(cè)觀，注意觀察心率，血壓，尿量變化等。（3）陰道出血，劇烈腹痛，脈搏快而弱，應(yīng)警惕有內(nèi)出血或休克。（4）遵醫(yī)囑給予5%葡萄糖500ml靜點(diǎn)給藥。2013.11.11 1.術(shù)前護(hù)理診斷：焦慮與恐懼及痛苦有關(guān)。護(hù)理措施：

（1）安撫患者緊張情緒，耐心熱情的設(shè)法消除其對(duì)手術(shù)的顧慮以及恐懼。（2）給與患者心理安慰以分散注意力減輕患者疼痛；必要時(shí)遵醫(yī)囑給予適量的止痛劑。

（3）做好剖宮手術(shù)的準(zhǔn)備工作。

2.手術(shù)護(hù)理診斷：疼痛、出血及并發(fā)癥與手術(shù)有關(guān)。護(hù)理措施：

（1）對(duì)患者進(jìn)行相應(yīng)的心理護(hù)理，分散注意力減輕患者疼痛；必要時(shí)遵醫(yī)囑給予適量的止痛劑。

（2）配合醫(yī)生進(jìn)行手術(shù)，予以相應(yīng)的體位護(hù)理、疼痛護(hù)理及并發(fā)癥的預(yù)防護(hù)理。

3.術(shù)后護(hù)理診斷：疼痛與手術(shù)創(chuàng)口有關(guān)。護(hù)理措施：

（1）醫(yī)囑給予心電監(jiān)護(hù)24小時(shí)，嚴(yán)密觀察呼吸、心率、血壓等生命體征的變化。

（2）持續(xù)氧氣吸入，禁食水靜脈留置針通暢，去枕平臥位休息。

（3）觀察術(shù)后有無出血情況，如傷口敷料有無滲出，陰道有無出血；觀察有無血壓下降脈搏快而弱，口唇面色蒼白，煩躁不安，出冷汗等內(nèi)出血征象，應(yīng)及時(shí)通知醫(yī)生。

2013.11.12護(hù)理診斷：焦慮與知識(shí)缺乏，對(duì)異位妊娠及剖宮術(shù)缺乏認(rèn)識(shí)相關(guān)。護(hù)理措施：

（1）了解患者的思想情況及對(duì)自身疾病的認(rèn)識(shí)程度，做針對(duì)性的宣教。向其介紹宮外孕的發(fā)病原因、手術(shù)步驟及治療方案，講述好轉(zhuǎn)病例增加患者對(duì)疾病好轉(zhuǎn)的信心。

（2）予以常規(guī)輸液護(hù)理，針對(duì)疼痛等并發(fā)癥進(jìn)行對(duì)癥處理。2013.11.13護(hù)理診斷：便秘，腹痛與手術(shù)有關(guān)。護(hù)理措施：

（1）消除或減少引起便秘的因素，根據(jù)病情給予易消化，富含維生素的飲食及水果，腹部按摩，增加胃腸蠕動(dòng)。

（2）囑患者排便時(shí)避免太用力或者屏氣，用力排便會(huì)影響腹部創(chuàng)口愈合或加劇疼痛。

（3）分散注意力減輕患者疼痛；必要時(shí)遵醫(yī)囑給予適量的止痛劑。2013.11.14護(hù)理診斷：綜合檢查，出院診斷 護(hù)理措施：

（1）常規(guī)檢查各項(xiàng)生命指征，B超檢查子宮恢復(fù)情況。

（2）詢問患者的感覺，有無不適，檢查創(chuàng)口及出血情況。與其溝通了解患者的患者神志狀態(tài)、食欲等，并予以相應(yīng)指導(dǎo)。

（3）予以出院指導(dǎo)，告知患者出院時(shí)間。

七、出院指導(dǎo)：

1、飲食指導(dǎo)：出院后給予患者高蛋白，高熱量，高維生素且易消化的飲食；少時(shí)生冷油膩的食物，多食用水果、蔬菜等高維生素食物，均衡營(yíng)養(yǎng)，加速康復(fù)。2.工作及活動(dòng)指導(dǎo)：出院后臥床休息7日，不可坐浴。7日后可參加全體力勞動(dòng)外的工作，避免接觸冷水，一個(gè)月后可正常工作；術(shù)后禁止性生活一個(gè)月，半年內(nèi)應(yīng)采取避孕措施，防止再次妊娠。養(yǎng)成良好的衛(wèi)生習(xí)慣，勤洗浴勤換衣，穩(wěn)定性伴侶。若伴有盆腔炎、陰道炎等婦科疾病應(yīng)徹底治療。

3.疾病預(yù)防指導(dǎo)：出院后按醫(yī)囑服用抗生素，預(yù)防術(shù)后感染。若出現(xiàn)腰酸、下腹部等癥狀時(shí)，及時(shí)進(jìn)行B超檢查，及時(shí)治療。

4.妊娠指導(dǎo)：有異位妊娠病史的患者，再次異位妊娠的可能性增加，對(duì)于還有生育要求的患者予以指導(dǎo)，妊娠前需通過B超檢查對(duì)子宮的恢復(fù)程度進(jìn)行評(píng)估，恢復(fù)良好后方可進(jìn)行妊娠，防止子宮破裂的并發(fā)癥的發(fā)生；懷孕前對(duì)輸卵管通暢度進(jìn)行檢查，以減少再次異位妊娠的發(fā)生率；因輸卵管妊娠患者再次發(fā)生宮外孕的幾率為10%，不孕率高達(dá)50-60%。所以再次妊娠時(shí)，應(yīng)及時(shí)就診，不要輕易終止妊娠。

八、討 論

護(hù)理病歷不僅能夠反映整個(gè)護(hù)理過程，而且為臨床治療及護(hù)理操作提供參考數(shù)據(jù)，對(duì)提高護(hù)理質(zhì)量，改善患者生活質(zhì)量，均具有重要的價(jià)值。護(hù)理病歷要求運(yùn)用護(hù)理程序護(hù)理患者，要求有系統(tǒng)、完整、能反映護(hù)理全過程的記錄，包括有關(guān)病人的資料、護(hù)理診斷、護(hù)理目標(biāo)、護(hù)理計(jì)劃及效果評(píng)價(jià)，構(gòu)成護(hù)理病歷。書寫要求詳細(xì)記錄、突出重點(diǎn)、主次分明、符合邏輯、文字清晰及正確應(yīng)用醫(yī)學(xué)術(shù)語。

此病例為婦科異位妊娠病歷，根據(jù)醫(yī)囑及患者的疾病、身體及心理特點(diǎn)，制訂了相應(yīng)的護(hù)理計(jì)劃，并按計(jì)劃實(shí)施，保證了手術(shù)的療效，贏得了患者的主動(dòng)配合，患者順利完成治療，心理及精神狀態(tài)良好，得到了患者的好評(píng)。綜合異位妊娠護(hù)理的臨床體會(huì)，主要有以下幾點(diǎn)：

（1）常規(guī)護(hù)理：患者圍手術(shù)期予以絕對(duì)臥床休息，按常規(guī)建立靜脈通道，并針對(duì)并發(fā)癥給予相應(yīng)藥物及補(bǔ)液護(hù)理。

（2）健康宣教：患者因疼痛、懼怕手術(shù)等常出現(xiàn)緊張、焦慮等不良心理，影響手術(shù)的依從性及療效。以此術(shù)前及術(shù)后需就手術(shù)的操作、療效、注意事項(xiàng)及療效等相關(guān)內(nèi)容進(jìn)行健康宣教。

（3）心理護(hù)理：針對(duì)患者不良心理予以相應(yīng)的心理護(hù)理，使患者自愿接受治療，消除不良心理，從而確保手術(shù)的療效及依從性。

（4）出院指導(dǎo)：就飲食、工作、活動(dòng)、疾病預(yù)防、妊娠等內(nèi)容進(jìn)行指導(dǎo)。尤其是再次妊娠指導(dǎo)尤為重要。因異位妊娠病史的患者，再次異位妊娠的可能性增加，再次妊娠前需通過B超檢查對(duì)子宮的恢復(fù)程度進(jìn)行評(píng)估，恢復(fù)良好后方可進(jìn)行妊娠，防止子宮破裂的并發(fā)癥的發(fā)生；懷孕前對(duì)輸卵管通暢度進(jìn)行檢查，以減少再次異位妊娠的發(fā)生率。以提高患者再次妊娠的安全性。

綜合所述，在異位妊娠護(hù)理過程中應(yīng)針對(duì)患者具體情況，做好健康宣教、心理護(hù)理及常規(guī)護(hù)理，護(hù)理過程中應(yīng)堅(jiān)持“以患者為中心”，采用規(guī)范的語言及肢體語言，熟練的操作，按要求完成護(hù)理操作。從而確保手術(shù)療效，提高護(hù)理的依從性。由此，證實(shí)護(hù)理操作具有重要的價(jià)值。

第三篇：婦科門診病歷書寫

姓名：羅珊 性別：女 出生日期：1975年10月25日 家庭地址：******* 過敏史：未發(fā)現(xiàn)

時(shí)間：2009年11月25日 主訴：停經(jīng)38天

現(xiàn)病史：lmp：09.10.16 停經(jīng)38天 自測(cè)尿液妊娠試驗(yàn)（+）既往史：體健

月經(jīng)史：14 4-5/28-30 量中等 痛經(jīng)（+）末次月經(jīng)：09.10.16 婚育史：1-0-2-1 末孕藥流 工具避孕 家族史：無特殊 體?。和怅帲阂鸦槭?/p>

陰道：暢，分泌物量中，乳白

宮頸：頸光，輕度糜爛，宮口可見一贅生物約綠豆大

宮體：前位，質(zhì)中，舉痛（-）

雙附件未及

初步診斷：早孕

處理：B超（孕80天左右）

腹痛、出血隨診

陳**

09.12.25 病史同前 lmp：09.10.16 停經(jīng)68天 陰道瘙癢 尿妊（+）PE:外陰：（-)陰道：暢，分泌物量少，略黃

宮頸：輕糜，宮壁粗糙，肥大 宮體：前位，質(zhì)中，舉痛（-）

雙附件未及

白帶Rt：細(xì)35% 三度 6：4 IMP:早孕

陰道炎 R/:克霉唑陰道片栓塞 qd*7 B超

腹痛、出血隨診

第四篇：婦科病歷書寫要點(diǎn)

婦科病歷書寫要點(diǎn)

婦科病歷

1．現(xiàn)病史

（1）閉經(jīng)：以往月經(jīng)情況，有無伴發(fā)癥狀及服用避孕藥或其他激素史。

（2）陰道流血：與月經(jīng)的關(guān)系、數(shù)量及持續(xù)時(shí)間。

（3）腹痛：發(fā)病時(shí)間、部位、性質(zhì)、與月經(jīng)的關(guān)系、以往有無類似發(fā)作史。

（4）腹部包塊：部位、增長(zhǎng)速度，有無疼痛或壓痛，有無對(duì)鄰近臟器的壓迫癥狀等。

（5）白帶：量、性質(zhì)、持續(xù)時(shí)間。

2．婚姻史

結(jié)婚年齡、丈夫健康情況，不孕癥患者應(yīng)詢問性生活史及丈夫精液檢查情況。

3．月經(jīng)史

應(yīng)較為詳細(xì)地記錄。

4．生育史

胎次、產(chǎn)次、分娩情況、末次妊娠時(shí)間。

5．體格檢查

（1）腹部檢查：形態(tài)，有無肌緊張、壓痛、反跳痛（尤其是下腹），有無腫塊（部位、大小、形狀、質(zhì)地、活動(dòng)度、壓痛）及移動(dòng)性濁音。

（2）婦科檢查：

外陰：已產(chǎn)式還是未產(chǎn)式，發(fā)育、陰毛、*、前庭大腺、會(huì)陰、尿道口情況，有無贅生物、畸形。陰道：發(fā)育、粘膜情況，有無畸形、分泌物及出血（量、色、氣味），白帶及其性狀。

宮頸：大小、質(zhì)地，是否光滑，有無裂痕、糜爛（輕、中、重度）、外翻、贅生物、舉痛。宮體：大小、形狀、位置、質(zhì)地、活動(dòng)度、壓痛、畸形。

附件：壓痛、腫塊大小、質(zhì)地、位置、活動(dòng)度，左右兩側(cè)分別查明并記錄。

第五篇：口腔科英文病歷

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