婦產(chǎn)科英文病歷

InpatientHistory

Name:XueJingfangSex:Female

Age:30yearWard:No.8

Maritalstatus:MarriedBirthplace:Kunshan

Nationality:HanProvider:Patient,reliable.

Recorddate:2012-08-07

G&OHistory:GW:31weeks,G2P0,LMP:2012-01-02;EDC:2012-10-09

ChiefComplaint:G2P0,GW:31weeks.Thispatientpresentsabdominaldistentionfor2days.

HistoryofPresentillness:

Thepatienthadregularmensespreviously.LMP:2012-01-02;EDC:2012-10-09.UricHcGtestwaspositiveafter30daysofamenorrhea.Fetalmovementswerefeltin4months’gestation.Thepatientdidn’tfeelanydiscomfortduringherante-partumexaminationinourhospital.ThepatienthasbeendiagnosedofSLEfor13years,withthesymptomsoffeverandfacialmaculae,thelargestdoseofprednisonewas8#/dduringthetreatment.Shehadsustainedtouseprednisone2#/d,hydroxychloroquinesulfate2#/d,aspirin2#/dfor3yearsbeforeandduringtheearlystageofthegestation.Inthe12weeks’gestation,ChiefPhysicianLinQiderecommendedtoaddapieceofNadroparinadaybecauseofthehigherrateofS/D,after5weeksoftreatment,aspirinwasreducedto1#/d,andtheuseofNadroparinwasstopped.ThepatientcametoourhospitalonJul.25thwiththediagnosisof“prematuresigns”,shefeltimprovedafter4daystreatmentofritodrine.Thepatientpresentsabdominaldistention2daysago,withoutvaginalbleedingorwaterrunning.ShewenttoKunshanFristRenMinHospitalbutstillfeltabdominalachingafterthetreatment.Bultrasoundshowedbilateralhydronephrosis,andThepatientdidin’tfeelbetteraftertheuseofCefmetazole.Shewasadmittedon-2012-08-07.

Afteradmission,sheappearsclear,withagoodappetite,goodsleeping,andnormalurinationanddefecation.

Pasthistory:thepatienthasbeendiagnosedofSLEfor13years.Denieshistoryofhepatitisandtuberculosis.Nohistoryofallergies.Vaccinatedregularly.Nohistoryofseveretraumaandtransfusion.Femoralheadofusingbonegraftin2007,Doublekneearthroscopicdecompressionoperationin2009

Reviewofsystems:

Respiratorysystem:Nohistoryofchroniccoughorbreathlessness.Nohemoptysisordyspnea.

Cardiovascularsystem:Noprecordialpain.Nopalpation.Nosyncope.Fordetailsseepresenthistory.

Gastroentestinalsystem:Nohistoryofchronicabdominalpainanddiarrhea;Nonauseaorvomiting;Nohematemesisandbloodstool.

Endocrinicsystem:Nopolydipsiaorpolyphasiaorpolyuria.Nosuddenchangeofcharacterandintelligence.

Hematologicsystem:Nobruisesorabnormalhemorrhage.Norecurrentoralulcerandgingivalbleeding.

Genitourinarysystem:Nodecreasedlibido;Novaginaldrynessorvaginalbleeding;HistoryofSTDdenied;Nourinaryfrequency.Noprecipitanturinationordysuria.Nohematuriaorproteinuria.

Neuropsychiatricsystem:Noconvulsionoranesthesia.Noheadaches.Noabnormalorientation.Nodeteriorationofmemoryorintelligence.

Locomotorsystem:Noarthralgia,nomuscularatrophiesordystrophies.

PersonalHistory:

BornandgrownupinKunshan.Patientdeniedhistoryoftobaccooralcoholuse.

MaritalandChildbearinghistory:Married.0-0-1-0;Shehadacurettagebecauseofinevitableabortionin2010

Familyhistory:NofamilyhistoryofDMorstroke.Nofamilyhistoryofnervousormentaldiseases.

PhysicalExamination

T:37.1℃P:80/minR:19/minBP:120/70mmHg

Generalappearance:Patientisa30yearsoldfemalewhoappearspleasant,innoapperantdistress,givenherage,welldevelopedandwellnourished.Orientedtoperson,placeandtime.

Lymphnodes:Notenlarged.

Skin:Nojaundiceorrashes.Nocyanosisandbruises.Noedema.

Head:Skullandscalpnormal.Notenderness.Nolossofhair.

Eyes:Noedemaineyelids,noptosis,noconjunctivalcongestion.Widthofpalpebralfissuresisnormal.Nojaundice.Pupil’ssizeandshapeisnormal.Cornealisclear.Noexophthalmos.

Ears:Auditoryacuityisexcellent.Noearpurulentdischarge.

Nose:Shapeisnormal.Noobstruction.Nodeviationofnasalseptum.

Mouth:Nolipsherpes.Nocyanosis.Nogumspyorrheaandbleeding.Notonguedeviation.Tonsilsnotenlarged.

Neck:Herneckissoft.Tracheaismidline.Nothyroidabnormalitywasfound.Neckveinwasnotdistended.

Chest:Contourisnormal.Nosternumtenderness.Thebreastsarebilaterallysymmetrical.Notendernessandmass.

Lung:

Inspection:Respirationregular.Degreeofexpansionissymmetry.

Plapation:Tactilefremitussymmetrical.

Percussion:extensiveresonancetopercussion.

Ausculation:Cleartoausculationwithnorubsnoted.

Heart:

Inspection:Noabnormalpulsationorretraction.

Plapation:Theapexbeatcanbefeltinthe5thintercostalspace1cminsideoftheleftmid-clavicularline.

Percussion:Theborderofcardiacisnotenlarged.

Ausculation:Theheartsoundswereofgoodqualityandtherhythmwasregular.

Heartrate:96/min.Nobruits.

Right(cm)RibinterspaceLeft(cm)

2Ⅱ2

3Ⅲ4

4Ⅳ6

Ⅴ8

Theleftmid-clavicularlineis9cmawayfromfrontmidsternalline.

Radialpulseisnormal.

Abdomen:

Inspection:Universialabdominalbulge.Dilatedveinsobserved.

Palpation:Soft.Liverandspleenisnotenlarged.Nontender.Murphy’ssignisnegative.Fordetailsseeobstetricexamination.

Percussion:Noshiftingdullness.Theupperborderoftheliverisinthe5thintercostalspace.

Ausculation:Bowlsoundclear.4/min.

Spineandextremities:Severeedemainbothlowerextremities.Noclubbedfinger.Nodisorderofthemovementofaxialandappendicularbones.

Reflex:Symmetrical,equalwithoutpathologicalresponses.BabinskisignandKernigsignandhoffmannsignareallnegative.

Obstetricexamination

Patientappearspleasant,givenherage,welldevelopedandwellnourished.Nojaundice.Noenlargedlymphnodes.

Fetus:Abdominalgirth:91cm;heightoffundus:26cm;fetalheartrate:150/min;FM:active.

Anorectalexamination:fetalmembrane:notruptured.

Flexionofknee:active.

Laboratoryandspecialexamination

Dec.6th,BloodRt:Hb:121g/L;PLT136×10e9

UrineRt:uricprotein(++);occludeblood:(+++)

Dec.7th,FetalUltrasound:BPD:78mm;HC:259mm;AC:238mm;FL:51mm;HL:49mm.fetalpresentation:head;Positionofplacenta:rightwallofuterus.Thicknessofplacenta:23mm.Degreeofplacentalmaturity:Ⅱ;fetalheartbeatandfetalmovementseen;amnioticfluid:64mm.Thereisnohematocoeliaorascites.Theloweredgeofplacentais23mmfromthecervix.

UmbilicalA:P2:0.87;R2:0.59;S/D:2.46.

Fetalheartrate:145/min

Dec.8th,24huricprotein:7.5g

Dec.10th,serumpotassium:3.9mmol/L

Scr:86umol/L

ALT:25U/L;AST:30U/L

Featuresofthecase:

Female,38yearsold,G2P0,GW:30+5weeks.

Thispatientpresentshypertensionfor3months,andsystemicedemafor2weeks.

PE:BP:180/120mmHg.Obstetricexam:Fetus:Abdominalgirth:93cm;heightoffundus:29cm;estimatedfetalweight:1600g;fetalposition:LOA;pointoffetalhearttone:;fetalheartrate:148/min;FM:active.

Flexionofknee:active.

Laboratoryandspecialexam:

Aug.7th,BloodRt:Hb:122g/L;PLT129×10e9;WBC7.13X10^9/L;N%77.5%H

UrineRt:uricprotein(-);LEU500/ulH

Aug.8th,ALT:11U/L;AST:18U/L

Diagnosisanddifferentialdiagnosis:

Diagnosis:G2P0,GW:31weeks.prematuresigns,SLE

Differentialdiagnosis:

1.Chronichypertensionduetorenaldisease.Thisincludeschronichypertensionduetointerstitialnephritis,chronicglomerulonephritis,SLE,diabeticglomerulosclerosis,andsoon.Intheseoccasions,thepatientwouldalsopossiblypresenthypertension,proteinuriaandedema,butherproteinuriawasfoundrecentlyandshedidn’thaveanysymptoms