急性胆囊炎病历模板(国外英文资料).docVIP

急性胆囊炎病历模板 The health hospital of mou ping town, yibin city Hospital medical records Codon: surgical name: the hospital number of reenen: 5798 Academy record Name: lei lianfen home address: mou ping village 4 groups Age: 43 years old: yibin Gender: female admission time: 2012-03-10 10:00 Marriage: married completion time: 2012-03-10 11:30 Occupation: medical history provider: patient Ethnic group: reliable: reliable Main complaint: the right upper abdominal pain is less than 10 hours Hpi: no significant incentives in patients with right upper quadrant persistent pain is not more than 10 hours, radiation to the right humeral back, accompanied by nausea, vomiting, no referred pain, lumbago, eyelid edema, no chest pain, amaurosis, syncope, heart tired, shortness of breath, hemoptysis, acid regurgitation, fever, symptoms aggravate 1 hour ago. The symptoms such as fear of cold, fever, chest pain, abdominal pain, diarrhea, urinary frequency, urgency, urine pain and other symptoms, such as symptoms, mental, sleep poor, appetite poor, urine and urine are no abnormal. Without diabetes, chronic nephritis, coronary heart disease, such as history, no history of trauma, surgery, blood transfusion, no food, drug allergies, vaccination history is unknown, no special systematic review. Born in the local area, there is no history of permanent residence, no epidemic disease, no history of contact, no smoking and drinking history, no special adverse life habits. Married. There is no history of such diseases as high blood pressure and diabetes in the family. Block check T: 36.6 ℃ P: 80 times/min R: 20 times/min BP: 130/70 mmHg Normal development, medium nutrition, clear mind, spirit, and cooperation. Whole body skin mucous membrane did not see Ban petechiae, stasis, no ulcer, skin rash, no subcutaneous bleeding, hair distribution is normal, no loose, fall off, normal temperature and humidity, elasticity is normal, no liver palm, spider angioma. There is no swelling of the superficial l