外一科急性阑尾炎大病历(国外英文资料).doc

外一科急性阑尾炎大病历 The peoples hospital of shizong county Hospital records Dont: ward: bed number: hospital no. : Name: gender: Age: name family: Marital status: nationality: Birthplace: occupation: Admission time: record time: Medical history: patients and their dependents are reliable: reliable Chief complaint: metastatic rightward pain hour in hospital. Hpi: patients and their families above the on hour ago no significant incentives in abdominal pain discomfort, gradually move to the belly button, after hours of transfer and limitations on the right lower abdomen. Pain is persistent, non-radioactive and involved, and pain relieves. No dizziness, headache, fearless cold, fever, cough, sputum, vomit, no sour, belching, urinary frequency, urgency, urine pain, diarrhea, purulent blood sample, constipation, and feeling of tenesmus. Patients had clinic (data), the outer court after feeling no pain relief, and for further diagnosis and treatment, as to our hospital, outpatient service to abdominal pain reason pending investigation (acute appendicitis? Admitted to our department. The patients disease duration, diet, sleep difference, two decrease, weight does not change significantly. Past medical history: patients with flat ferrite, denied diabetes, high blood pressure, such as chronic medical history, deny hepatitis, TB, such as infection history, deny that history of surgical trauma, denied food and drug allergy history, history of vaccination is unknown. Blood transfusion history: denial of history of blood products. Personal history: born of origin, has never been in an epidemic area, denied bad habit, has no radioactive material and poisonous material contact history, deny the history of smelt. Menstruation and marriage history: (male patients deny menstrual history) Family history: denial of family history, parents Physical check General situation: T: P: R: BP: Development: normal nutrition: medium length, body weight, body position: passive awareness: ill: acute pain S