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妇科.doc

妇科

lyl4018
2012-02-15 0人阅读 举报 0 0 暂无简介

简介:本文档为《妇科doc》,可适用于自然科学领域

CASEMedicalNumber:GeneralinformationName:YingJiaAge:ThirtytwoSex:FemaleRace:HanOccupation:PublicfuntionaryNationality:ChinaMaritalstatus:MarriedAddress:NO,HangkongRoad,JiefangRvenue,Hankou,HubeiTel:nonDateofadmission:Dateofrecord:Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:HysteromyomahavebeenfoundthroughphysicalexaminationformorethanoneyearPresentillness:mensesregularfirstcameyearsolddmiddleamountwithoutbloodclot,slightpainandcanbetolerantLMPamountocularasbeforeHysteromyomahavebeenfoundthroughphysicalexaminationformorethanoneyear,size*cmWithnosystemtreatmentDemandforoperationtreatmentnowascomingtoourhospitalPatientwithnofever,tired,dizzy,abdominalpain,orabnormalbleedingfromvaginaSleepanddietasnormalweightdoesnotreducePasthistory:haveresectionofadrenaltumorininPGartificialabortiononcespontaneouslaboroncenfectioushistory:NohistoryofsevereinfectiousdiseaseAllergichistory:ShewasnotallergictopenicillinorsulfamideRespiratorysystem:NohistoryofrespiratorydiseaseCirculatorysystem:NohistoryofprecordialpainAlimentarysystem:NohistoryofregurgitationGenitourinarysystem:NohistoryofgenitourinarydiseaseHematopoieticsystem:NohistoryofanemiaandmucocutaneousbleedingEndocrinesystem:NoacromegalyNoexcessivesweatsKineticsystem:NohistoryofconfinementoflimbsNeuralsystem:NohistoryofheadacheordizzinessPersonalhistoryNobadpersonalhabitsandcustomsMenstrualhistory:ThefirsttimewhenshewasLastingdayseverytimesanditscycleisaboutdaysObstetricalhistory:Ptimes,oncenatureproduction,abortiononceContraceptivehistory:NotclearFamilyhistory:HysteromyomaPhysicalexaminationT℃,Pmin,Rmin,BPmmHgSheiswelldevelopedandmoderatelynourishedActivepositionTheskinwasnotstainedyellowNocyanosisNopigmentationNoskineruptionSpiderangiomawasnotseenNopittingedemaSuperficiallymphnodeswerenotenlargedHeadCranium:HairwasblackandwelldistributedNodeformitiesNoscarsNomassesNotendernessEar:BilateralauriclesweresymmetricandofnomassesNodischargeswerefoundinexternalauditorycanalsNotendernessinmastoidareaAuditoryacuitywasnormalNose:NoabnormaldischargeswerefoundinvetibulumnasiSeptumnasiwasinmidlineNonaresflaringNotendernessinnasalsinusesEye:BilateraleyelidswerenotswellingNoptosisNoentropionConjunctivawasnotcongestiveSclerawasanictericEyeballswerenotprojectedordepressedMovementwasnormalBilateralpupilswereroundandequalinsizeDirectandindirectpupillaryreactionstolightwereexistentMouth:Oralmucousmembranewassmooth,andofnoulcerorerosionTonguewasinmidlinePharynxwasnotcongestiveTonsilswerenotenlargedNeck:SymmetricandofnodeformitiesNomassesThyroidwasnotenlargedTracheawasinmidlineChestChestwall:VeinscouldnotbeseeneasilyNosubcutaneousemphysemaIntercostalspacewasneithernarrowednorwidenedNotendernessThorax:SymmetricbilaterallyNodeformitiesBreast:SymmetricbilaterallyNeithernipplesnorskinwereretractedElasticitywasfineLungs:RespiratorymovementwasbilaterallysymmetricwiththefrequencyofminThoracicexpansionandtactilefremitusweresymmetricbilaterallyNopleuralfrictionfremitusResonancewasheardduringpercussionNoabnormalbreathsoundwasheardNowheezesNoralesHeart:NobulgeandnoabnormalimpulseorthrillsinprecordialareaThepointofmaximumimpulsewasinthleftintercostalspaceinsideofthemidclavicularlineandnotdiffuseNopericardialfrictionsoundBorderoftheheartwasnormalHeartsoundswerestrongandnosplittingRateminCardiacrhythmwasregularNopathologicalmurmursAbdomen:FlatandsoftNobulgeordepressionNoabdominalwallvaricosisGastralintestinaltypeorperistalseswerenotseenTherewasnottendernessandreboundtendernessonabdomenorrenalregionLiverwasnotreachedSpleenwasnotenlargedNomassesFluidthrillnegativeShiftingdullnessnegativeBorhorygmusminNovascularmurmursExtremities:NoarticularswellingFreemovementsofalllimbsNeuralsystem:PhysiologicalreflexeswereexistentwithoutanypathologicalonesGenitourinarysystem:NotexamedRectum:notexanedInvestigationNoProfessionalExaminationPelviccavityColordopplarultrasoundshow(,ShengJinghospital):Theuteruspostsize**cm,endometrialcm,alowresponseshadowonleftwallofcervicalboundaryisclearLeftovariansize*cmrightovariansize*cm。noseriouslyabnormalsigncanbeseenShowHysteromyomaVulvovaginalcandidiasisnormal,VaginalNormal,mucosanobleeding,secretionmiddleamountwhiteandnoabnormalsmellcervicalsmoothTheuteruspostsize**cm,endometrialcm,alowresponseshadowonleftwallofcervicalboundaryisclearLeftovariansize*cmrightovariansize*cm。noseriouslyabnormalsigncanbeseenShowHysteromyomaImpression:HysteromyomaSignature:LingOuyang

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