Admission Note
Name: Zhou Yifei
Sex: Female
Age: 29
Marital status: Married
Nationality: Han
Birth place: Shanghai
tamatoOccupation:
Job Unit:
Address:
Date of admission: 2011-10-24
Date of record: 2011-10-24
Provider of medical history: Patient himlf (reliable)
Source of patient: Emergency
40 weeks pregnant, G1P0, EDC: 2011-10-24, LMP: 2011-01-17
Fetal membranes: unruptured
No diarrhea, hepatitis, bath, intercour for a week.
Chief complaints
G1P0, 40 weeks pregnant, irregular abdominal pain for 6 hours.
Prent illness
The patient has a regular menstruation, 7/25days, LMP: 2011-01-17, EDC: 2011-10-24. Pregnancy test result showed HCG was possitive when cessation of menstruation for 30
days. She has light morning sickness, and little vaginal bleeding in early pregnancy. After intramuscular injected of progestorone, she got better. The patient has been feeling fetal movements since 4 months pregnant. She made her card in our hospital when 14+1 weeks pregnant, and obstetric examined regularly. No abnormal findings in prenatal screen. GCT: 8.4mmol/L and she rejected to do OGTT. The blood type of the patient is O, and of her husband is B, Anti-B IgG: <1:64. No dizziness, no headache, no chest tightness, no palpitation, no blurred vision, no abdominal pain, no vaginal bleeding or watering and no skin itching during the late stage of pregnancy. Now she is 40 weeks pregnant, felt irregular abdominal pain for 6 hours, last 10 mintutes for each time. The patient sleeps good in the night. And NST showed no respond.
The patient was in good nutritional and conscious condition since pregnant. Body weight incread normally.
Past medical history
No history of www tubecup comHBV infection. No history of trauma. No history of blood transfusion. Vaccin
ated regularly. Myopia both eyes of 600 degrees. History of rection of bilateral breast fibroma and lar surgery on eyes.
Head: No dizziness. No poor vision. No ear purulent discharge. No hearing lo. No chronic running no and nasal stuffiness. No rash. No hair loss.
Respiratory system: Plea refer to the prent illness.
Circulatory system: No palpation. No edema in lower extremities. No precordial pain. No syncope.
Digestive system: No vomiting and diarrhea. No hematemesis and bloody stool.
Endocrine system: No polydipsia or polyuria or polyphagia.
Hematologic system: Dizziness. No fatigue, paleness, bleeding spots, or rash.
Genitourinary system: No dysuria. No urinary frequency. No precipitant urination or urodynia. No hematuria.
Neuropsychiatric system: No convulsion and anesthesia. No headaches. No abnormal orientation.
Personal history
Born and growth in Shanghai. None addicted to alcohol or smoking. No history of epidemic prence. No pets at home.
Marital history
Married.
Reproductive history
0-0-0-0
Family history
Unkown
Physical examination
Temperature：37.0℃, Pul：82bpm, Respiration：20bpm, Blood pressure：120/66mmHg
General appearance：The patient was in moderate distress, well developed and nourished. No shortness of breath. Height: 164cm.
poweroff
Lymph nodes：Not enlarged.
Skin：No jaundice. No cyanosis and bruis. No liver palm or spider angioma.
Head：skull and scalp normal. No tenderness. No hair loss.
Eyes：No edema in eyelids, ptosis, no conjunctival injection. Width of palpebral fissures is normal. No jaundice, Pupils’ size and shape is normal. Corneal is clear. No exophthalmos.
Ears：Auditory acuity is excellent. No ear purulent discharge.
No：Shaped is normal. No obstruction. No deviation of nasal ptum.
Mouth：No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. No caries and fal teech. Tonsils not enlarged.
Neck：His neck is soft. Trachea in the midline. Neck vein was not distended. No thyroid enlargement.
Chest：Contour is normal. No sternum tenderness.
Lungs：
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Inspection：Degree of expansion is equal bilaterally.
神谴Palpation：Tactile fremitus symmetrical on both sides.
Percussion：Lung fields clear to percussion without dullness or hyperresonance.
Auscultation：Breath sounds are clear without pathological sounds or rales.
Heart：
Inspection：中秋节英语No abnormal pulsation.
Percussion：The heart percusd normal in size.
Auscultation：Heart rate of 82/min. The heart sounds are no splitting. No pathological murmurs.
Abdomen：
Inspection：No scar and no dilated vein en. No gastral or intestinal pattern. No peristalsis.
amsPalption：Murphy’s sigh is negative. Liver and spleen are not palpable. Contractions every 10 mintues, lasts for 15 conds, weak. ROA. FHR: 140bpm. Abdominal circumference: 102cm. Fetus approximate weight: 3700g.
xfh>会计软件有哪些Percusson三星手机广告曲：No shifting dullness. The upper border of the liver is in the 5th intercostal sp
ace inside of the right mid-clavicular line. No percussion pain in liver area. Renal region：No percussion pain.
Auscultation：No vesl murmur.
Spine and extremities：No edema in lower extremities. No clubbed finger.
Neural：Physiological reflexes are prent without pathological reflexes.
Genitourinary system：Normal.
Pelvic cavity: IS: 24cm, IC: 26cm, EC: 20cm, IT:8.5cm.
Laboratory findings
None
Special procedures
