外科英文病例模板外科英文病例模板.docVIP

CASE Medical Number: 682786 General information Name: Ding Zier Age: Forty seven Sex: Female Race: Han Occupation:farmer Nationality: China Marital status: Married Address:jianli county，Jingzhou City,Hubei Province Date of admission: April 17, 2013 Date of record: April 17, 2013 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Intermittent low back pain for 10 years Present illness: Ten years ago, the patient suddenly felt pain in the lower back, with hematuria , but no urinary frequency, urgency, dysuria, fever and other symptoms.After the Left kidney stones removal surgery, Patients with low back pain relief.Five years ago, patients felt intermittent low back pain with urinary frequency, urgency again, no dysuria, hematuria, fever and other symptoms, the patient didn’t treat it. 2013-02-24 reviewed the ultrasound found that Left kidney stones .For the sake of further treatment, then come to our hospital, outpatient revenue to Left kidney stones to our department. Since the onset, the patients private prosecution spiritedness, appetite, sleep somewhat less, slightly more urination, defecation is normal, no significant changes in physical weight. Past history Operative history: 10 years ago,did kidney stones removal surgery. 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 Jianli County and almost always lived in Jianli cou