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resident admission note产科英文病例

产科英文病例

Hospitalization Records

Admission number:612984

Identifying information:

Name:Zhow Jingzhe Gender:Female

Age:28 Occupation:

Nationality: Han Marital status:Married Birth Place: Shanghai Job Unit:

Address:

Date of admission: Nov. 25, 2010

Date of record: Nov. 25, 2010

Gestation ages:39+5weeks

Generation: 0 time Pregnancy:1 time

LMP: 2010-02-20 EDC: 2010-11-27

Fetal membrane: Intact

Has no history of diarrhea, hepatitis, tub bath and sex in the last week.

Provider of medical history:Herself (reliable)

Chief Complaint:

G1P0, having generated for 39+5 weeks, bloody show for 4 hours.

Present illness:

The pregnant woman has a regular menstrual cycle ordinarily. The periods was 33-35days and lasted for 5 days. Last menstrual period:2010-02-20. The HCG in urine was positive on the 30th days after menelipsis. Morning sickness was not serious. Had no bloody show at the first trimester. Progesterone was used to treat “bellyache”. Feeling fetal movement since the 4th month of pregnancy. Had the 1st antenatal examination when generated for 15 weeks. Has regual obstetrician visit and D screening test was done in Xinhua Hospital. The result of US was normal. GCT:8.9mmol/L, OGTT was normal. During the gestation the pregnant woman has no dizzy, headache, blurred vision, bellyache, vaginal discharge or itch of skin. This morning she had a bloody show without bellyache and vaginal discharge and was admitted. The fetal movement was normal in the last few days. No symptoms of abdominal pain and distension. Her general condition was good. The appetite, sleeping, stools and urine were normal.

Past Medical History:

Had a history of excision of benign tumor of breast.

No history of infectious disease such as hepatitis, tuberculosis,

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