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出国看病就医,需提前翻译门诊病历英文版

发布时间:2020-01-15 21:28:06
 

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Beijing Haidian District Maternal and Child Health Hospital

Outpatient case report

Name

Sex: female  Age: 31

Dept.: prenatal screening

Case No.:677200

Date of return visit: 09:01, August 22, 2019    Gestational age: 15 weeks4d

Chief complaint: non.

Pregnant women in the peking university 3rd hospital endocrinology department, no special treatment, postpartum review is recommended.

Examination: blood pressure 109/73mmhg, weight 65kg, fetal HR150/MIN, unclear position, floating head, lower limb edema (-).

Auxiliary examination: urine routine: common genetic test for deafness, no indication of obvious abnormality Down’s syndrome after screening

diagnosis: pregnancy at 15" weeks4d.  hyperprolactinemia 

Treatment :2 weeks of return, next routine: prenatal examination, blood routine, urine routine.

Signature: Meng Ran

Date of return visit: 13:48, September 16, 2019   Gestational age: 19 weeks 1d.

Chief complaint: no discomfort.

Check: bp 117/72 MMhG, weight 70 kilograms, cervical height 19 cm, with 92 cm of abdominal parameter, hr 150 times/min, fetal position is not clear, the presentation is unknown, lower limb edema (-).

Auxiliary examination: urine routine: protein-g /L, glucose-mmol /L, normal bone density, blood routine:, combined screening for early and middle pregnancy are low risk; non-invasive DNA* hemoglobin 123g/L,

Diagnosis: pregnancy. 19weeks1d ; hyperprolactinemia

Treatment: color doppler ultrasound for fetal malformation screening should be performed at 20-24 weeks of gestation, and color Doppler ultrasound should be scheduled for 2 weeks. The next routine: prenatal examination. Control your weight.

Pregnancy 21trisomy screening risk value is 1:297, low risk, but is close to 1/270 high risk cutting value, explain the chromosome disease (fetal mental retardation, stunted growth, may merge cardiac malformation, gastrointestinal tract malformation, etc.), the limitations of serologic screening is informed; suggested that color doppler ultrasound at22-24w conduct screening for fetal malformation, if discovery any unusual, go to the prenatal diagnosis clinic; suggested further screenings of pregnancy abnormality such as peripheral blood cell-free fetal DNA prenatal check. Explain to pregnant women the limitations and inaccuracies of prenatal screening for fetal free DNA in maternal peripheral blood, and the possibility of false negative(especially for those with sex chromosome abnormalities such as Turner syndrome). Pregnant women agreed understanding and required non-invasive DNA screening. Then signed it.                  

Signature: Meng Ran

Gestational age: 23 weeks4d;Date of return visit: 13:29, October 17, 2019

Chief complaint: no discomfort.

Examination: blood pressure 120/72mmhlg, weight 72 kg, uterine height 22cm, abdominal circumference 96cm, fetal heart 150 times/minute, unclear fetal position, unknown first exposure, lower limb edema (-).

Auxiliary examination: urine routine examination: protein-g /L, glucose-mmol /L, prenatal screening report of fetal free DNA in peripheral blood, showed: fetal trisomy 21, trisomy 18 and trisomy 13 syndrome were all low-risk, b-ultrasound 22+4weeks, blood routine examination :* hemoglobin 121g/L, diagnosis: in pregnancy. 23+4 weeks of gestation  Hyperprolactinemia

Treatment: after 2 weeks, returned hospital next routine prenatal examination, recheck B ultrasound, OGTT, pelvic measurement + leucorrhea routine                                                                                                    Signature: Meng Ran

Gestational age: 25 weeks4d  Date of return visit: 11:37, October 31, 2019

Chief complaint: no discomfort, good fetal movement.

Check: blood pressure is 131/75 MMhG, weight 74 kilograms, uterine 25 cm tall, abdominal circumference 97 cm, fetal heart 142 times/min, fetal position is not clear, the presentation is unknown, lower limb edema (-).Auxiliary examination: urine routine: OGTT: normal

Diagnosis: in pregnancy  25 weeks4d

Treatment: if has abnormal fetal movement, abdominal pain, vaginal exccess fluid, blood appearance, go follow-up;  3 weeks later go back for recheck, the next routine prenatal examination, pelvic measurement + leucorrhea routine. .                                                                                                                                                                                    Signature: Chen han

 

Date of return visit: 13:14, November 21, 2019 Gestational age: 28 weeks4d

Chief complaint: no discomfort.

Examination: bp 131/67mmhg, weight 76 kg, uterine height 27cm, abdominal circumference 101cm, fetal heart 146 times/min, fetal LOA, floating head, lower limb edema (-).

Auxiliary examination: urine routine: protein-g /L; Cleanliness II degree;

Diagnosis: IN pregnancy  28 weeks4d.


 

Beijing Haidian District Maternal and Child Health Hospital

 

Outpatient case report

 

Name

Sex: female  Age: 31

Dept.:   prenatal screening

Case No.:677200

 

Treatment: return to the hospital after 2 weeks, suggested with self-count fetal movement, follow-up if abnormal fetal movement, regular abdominal pain or vaginal fluid or discomfort; next time routine check: prenatal examination, b-ultrasound, blood routine, biochemical D       Signature: Wang Lin

 

Date of return visit: 08:35 on December 11, 2019

Gestational age: 31 weeks 3d.

 

Chief complaint: no discomfort, good fetal movement, No sign of pregnancy.

Examination: blood pressure 121/75mmhg, weight 78kg, uterine height 28cm, abdominal circumference 102cm, fetal heart 140 times/min, fetal position LOA, first exposed floating, lower limb edema (I). The

Auxiliary detection: urine routine: protein-g /L; Ketone -mmol/L: mycoplasma culture + Drug-Sensitivity positive (+); * alanine aminotransferase 46.61U/ L; * aspartate aminotransferase 25.45u /L: total bile acid 4.14umol /L; * 5.26 mmolL for blood sugar/L; * leucocyte 9.4*10-9/L; * hemoglobin132g/L ; * platelet count 202*10'9/L; B ultrasound: af115.45 cm, normal blood flow in umbilical artery. Head position (gestational week: 31 weeks 1 d)

Diagnosis: in pregnancy.  31 weeks3d; Gestational diabetes, liver function abnormal?

Processing: gestational diabetes, postscript nutrition clinic, high-risk registration, to tell the patient: gestational diabetes pregnancy which may cause diseases such as possible ketoacidosis, gestational hypertension, polyhydramnios, macrosomia, innate malformation fetus, fetal distress and fetal intrauterine death, dystocia, urogenital infection, puerperal infection and neonatal hypoglycemia, and respiratory distress syndrome, low blood calcium, complications such as disease of grow in quantity of red blood cells, so pregnant women should pay great attention to, a found the disease, should be under the guidance of strict diet, if blood sugar control are not satisfied, when it is necessary to insulin therapy. Regular monitoring of blood glucose, urine ketone body and fetal growth and development. The patient understood. Outpatient service of nutrition department, receiving dietary guidance: fasting examination after one week: fasting blood glucose, 2h postprandial blood glucose, glycosylated hemoglobin, urine routine.

The pregnant woman requested to have a prenatal examination in her hometown and give birth. She is advised to establish a file for prenatal examination at the local hospital as soon as possible, monitor blood glucose regularly, stop using elevit, and reexam liver func. after 2 weeks

 

Signature: Chen han



 

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