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发布者:鑫达医学翻译 发布时间:2013-04-02 8:50:52 阅读:

原文:
既往史:否认明确高血压、冠心病、高脂血痛病史,否认慢性孩嗽、咳痰、哮喘病史、否认结核肝炎病史,近期发现右侧乳腺质硬结节,拟行手术治疗,曾行剖腹产术及人工流产术,否认输血史,否认食物过敏史,青霉素皮试(+)。
个入史:近一年吸烟,每周2-3日,每日10-20支,偶有饮酒,饮白酒,近3月未再饮。平素饮食可,喜食肉类,平素工作压力较大。
月经婚育史:无特殊。
家族史:母40余岁患“冠心病”,53岁患高血压,祖父患糖尿病,冠心病。

 

译文:
Past history: Normal health condition was obtained based on the previous physical examination. No regular physical examination was performed. The patient denied histories of hypertension, coronary heart disease, hyperlipidemia, chronic cough, expectoration, asthma, tubercle and hepatitis. A hard tubercle was noted in the right lacteal gland in the recent days. The patient received cesarean section and induced abortion in the previous days. No history of blood transfusion and food allergy was reported. Penicillin skin test was positive.

Personal history: The patient denied history of drug addiction and access of radiogen. She has smoked for nearly 1 year with a frequency of 2 to 3 days per week (10-20 cigarettes per day). She had a history of drinking alcohol. However, she did not drink in the recent three months. The patient had a satisfactory appetite, especially for meat. She worked with great pressure.
Menstruation and marriage: No abnormality was observed.

Family history: Her mother suffered from coronary heart disease at the age of 40 years old. Then she was diagnosed with hypertension at the age of 53. Her grandfather suffered from diabetes and coronary heart disease.
 


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