【医务文件类】
入院记录
1.急性阑尾炎
Acute Appendicitis
Admission Certificate
Oct.23.2005
This is to certify that Mr.Milton,male,aged 43.is suffering from acute appendicitis.It is suggested that he should be immediately hospitalized and operated 0n Chen Ye-de
Surgeon in Charge
(Seal)
入院治疗证
现证明密尔顿先生,男,43岁,患急性阑尾炎,建议立即住院施行手术.
外科主治医师陈叶德
(医院公章)
2005年10月23日
2.慢性肾盂肾炎急性发作
Chronic Pyelonephritis with Acute Attacks
Admission Notes
A 42一year-01d unmarried female gained admission to the hospital on August 26,2005 because of urgency and frequency of micturition and a right lumbago, which have each 1asted for over twenty days.
More than twenty days ago, she began experiencing urgency and frequency of micturition,urinating almost once an hour with a slight right 1umbago at the same time;she,therefore,went to a hospital for a urine test on August 10,2005. Microscopy:WBC 6～8/HPF.Pus cell 8～12/HPF.
Findings of urine culture:Bacnliproteus,which are sensitive to chloromycetin,were isolated.
After a 7一day course of treatment with the medicine,there was a considerable decrease in the frequency of urination.As she still felt weak,she came to Rotifunk Hospital for further treatment.
She has not suffered from fever,cough or vomiting and there has been nothing specific in her stools in the course of her illness either.
In the two simi1ar attacks,which happened in 1998 and in August 2004 respectively,the diagnosis 0f pyelonephritis was established.
Her menstrual cycle is normal.
PET:37℃;P:82/min;R:20/min;BP:120/70mmHg(16/9kPa).
General condition good.No jaundice on skin.Superficial lymph nodes not felt.Heart not enlarged. No murmur heard. Lungs negative.Abdomen soft.Liver and spleen impalpable.Tenderness over right kidney region detectable. Bowel sounds normal.Spine and extremities not abnormal.Knee jerk present.No path010gical reflex observable.

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