口腔科英文病歷

1、Oral and Maxillofacial Surgery Complete Medical History (Zhang te) General information Name: Tao lili Age: Forty eight Sex: Female Race: Han Occupation: worker Nationality: China Marital status: Married Address NO.138,mawa ngdui Medical Number:佃2786 Rvenu e,cha ngsha, Hunan. Tel: 84722500 Date of ad

2、mission Jun 20st, 2013 Date of record: 11Am, Jun 20st, 2013 Complainer of history: the patient herself Reliability: Reliable Chief complaint: lower incisors gingivae mass found for more than 3 mon th. Present illness:3 month ago, the patient suddenly found a small mass on lower in cisors gin givae.

3、After touchi ng it, she found a mass tendn ess, She did not get fever ,dizz in ess, vertigo and headache.the patie nt did n pay attention it. Then the mass became more and more bigger, so the patient she came to our hospital and asked for an operati on. Since on set, her appetite was good, and both

4、her spirited ness and physical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never un derg oing any operati on. Infectious history:No history of severe in fectious disease. Allergic history: She was n ot allergic to peni cilli n or sulfamide. Respirator

5、y systemNo history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitati on. Genitourinary system: No history of gen itouri nary disease. Hematopoietic system: No history of anemia and mucocutaneous bleed ing. Endocrine system No acro

6、megaly. No excessive sweats. Kinetic system:No history of confinement of limbs. Neural system: No history of headache or dizz in ess. Personal history She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuha n. She graduated from senior high school. Her livi ng con diti ons were good.

7、 No bad pers onal 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 pare nts have b

8、oth died. Physical examination T 364C, 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 cyano sis. No pigme ntati on. No ski n eruptio n. Spider an gioma was n ot see n. No pitt ing edema. Superficial lymph no des

9、were not enl arged. Head Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No ten der ness. 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 n ormal. Nose

10、: 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. Conjun ctiva was not con gestive. Sclera was ani cteric. Eyeballs were not projected or depressed. M

11、oveme nt was n ormal. Bilateral pupils were round and equal in size. Direct and in direct pupillary reacti ons to light were existe nt. Neck: Symmetric and of no deformities. No masses. Thyroid was not enl arged. Trachea was in midli ne. Chest Chestwall: Veins could not be see n easily. No subcuta n

12、eous emphysema. In tercostal space was n either n arrowed nor wide ned. No tendern ess. 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

13、 of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard dur ing percussi on. No abno rmal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximu

14、m impulse was in 5th left in tercostal space in side 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 bulg

15、e or depression. No abdominal wall varicosis. Gastrali ntest inal type or peristalses were not see n. There was not tendern ess and rebo und tendern ess on abdome n or renal regi on. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhoryg

16、mus 5/min. No vascular murmurs. Extremities: No articular swelling. Free movements of all limbs. Neural system: Physiological reflexes were existent without any pathological on es. Genitourinary system: Not examed. Rectum: not exa ned Investigation No. Professional Examination Oral mucous membra ne

17、was smooth, and of no ulcer or erosi on. Ton gue was in midline. Pharynx was not congestive. Tonsils were not en larged.Patie nts with poor oral hygie ne has much den tal calculus .There are a about 2*2*1.5cm mass on lower in cisors(33-41) gin givae. It is ten der but not bleed. It can not be moved

18、and its surface is smooth. Corresponding superficial lymph no des don t enl arge. Impressi on: Epulis Sig nature: Zha ng te Hospital course record for the first time 2013-6-20 8:50 、 Characteristics of cases 1. CIinical presentation:Patient was a worker , female, 48 years old. 2. lower in cisors gin

19、 givae mass found for more tha n 3 mon th. 3. No special past history. 4. Physical exam in atio n showed no abno rmity in lung, heart and abdoma n. In formati on about her oral can be see n above. 5.Shorting of investigation information. 6.Temperature is36.5S , pulse 80, respirations 20, blood press

20、ure 90/60. 二、Exam in ati on to discuss diagnostic basis 1ower incisors gingivae mass found for more than 3 mon th。2. She did not get fever ,dizz in ess, 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 m

21、ass on lower incisors(33-41) gin givae. It is ten der but not bleed. differential diagnosis Gingival carcinoma : Except fast growth, it can appear local can ker, pain, involving related to teeth. ADMITTING DIAGNOSIS:Epulis 三、Case classification A 四、Treatment plan : 1.To improve the routine inspectio

22、n.2.Whole mouth clea n gover nan ce.3.Opti onal operatio n. Xu yuguo Hospital records 2013-6-21 The patie nt was hospitalized on this morni ng.with sudde nly found a small mass on lower in cisors gin givae 3 month ago. tran spare nt mild red ness, lining color is normal, Patients usually in good hea

23、lth. Blood, urine, dung routine has been sent, liver and kidney function checklist to fill in, check the doctors advice already ope n.Pathological biopsy for the diseased tissue has bee n sent. Xu yuguo 2013-6-23 This morni ng Pro. zha ng visits, the diag no sis and treatme nt of put forward the fol

24、lowing opinions:Pathological biopsy result has shown Epulis. All investigation is normal. According to the clinical manifestations of it ,this disease The disease can be diag no sed with Epulis.Gum tumor resecti on Can be imposed immediately.Preoperative should be whole mouth clean gover nan ce.surg

25、ery will be done at eight on tomorrow morning . Zhang te/ Xu yuguo 2013-6-24 Preoperative SUMMAR Y Patient was a worker , female, 48 years old. lower incisors gingivae mass found for more tha n 3 mon th. No special past history.Physical exam in ati on showed no abno rmity in lung, heart and abdoma n

26、. In formati on about her oral can be see n above.All inv estigati on is no rmal.whole teeth have bee n cleaned. Surgical treatment plan: (1) pastoperative biopsy to determine the tumor nature; (2) Complete removal of the tumor and spread of the period on tal membra ne, teeth and gums. (3) a man dib

27、ular defect should still depe nding on the n ature of the tumor and the n make a decisi on whether to immediately bone graft, but should be ready to immediately bone graft. (4) preoperative for teeth clea ning and use of an tibiotics. Xu yuguo 2013-6-25 8:15 Operati on records Make Routine local ane

28、sthesiaon the patient supine, disinfection and shop towels according to Maxillofacial surgery routine. lump completely and spread of the period on tal membra ne, and gums bee n removed with electricity knife. hydrogen peroxide and saline flush incision.Mass was sent to Pathological biopsy.The patien

29、t went back the ward safetyly at 9:30 , The surgery was over. Zhang te 2013-6-26 Pastoperative records T 36.5C , P 80/min, R 23/min, BP 100/60mmHg. Patients feel the wound and teeth pain is severe, the wound n ear swolle n gums, jaw was covered with a little fake. Con ti nue to An algesic, an ti-i n

30、flammatory.Pay atte ntio n to mai ntai n oral hygie ne. Patie nts require to discha nge tomorrow, he Would be approved to agree with. Zhang te DISCHARGE RECORD DATE OF ADMISSION: Jun 20st, 2013 DATE OF DISCHARGE: J un 26st, 2013 Number of days in hospital:6 Days ADMITTING DIAGNOSIS: Epulis BRIEF HIS

31、TOR Y 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 ,dizz in ess, vertigo and headache. the patie nt did n t pay atte ntio n it. Then the mass became more and more b

32、igger. REVIEW OF SY STEM 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, accide nts or childhood ill ness. SOCIAL HISTOR Y: She has no history of excessive alcohol or tobacco use. FAMIL Y HISTORY She has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHY SICAL EXAMINATION Temperature is365C , pulse 80, respirations 20, blood pressure 90/60. General: Plump girl in no apparent distress. HEENT: She has no s