glittering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.

th

e

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

ts 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