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首页 血液科英文病历

血液科英文病历.doc

血液科英文病历

只求yi份安稳的温存
2019-01-11 0人阅读 举报 0 0 暂无简介

简介:本文档为《血液科英文病历doc》,可适用于医药卫生领域

MedicalRecordsforAdmissonMedicalNumber:GeneralinformationName:YuXinwenAge:Sex:maleRace:HanNationality:ChinaAddress:Shimentown,Changdecity,HunanprovinceDateofadmission::,Aprilst,Dateofrecord::,Aprilst,Complainerofhistory:YuXinwenReliability:ReliableChiefcomplaint:Palpitationandtremorofhandsforyear,andblurredvision,photophobiaandtearsformonthsPresentillness:ThepatientfeltpalpitationandtremorofhandsinApril,,accompaniedbythesymptomoffatigueNosignsoffever,diarrheaandexophthalmosesHecametothelocalhospitalandreceivedtherelatedtherapy(notclear),diagnosedashyperthyroidism,butdidnotgetsignificantlybetterInAugust,thepatientbegantotearoutofcontrol,butdidnotreceiveanytreatmentInOctober,hehadswellingoftheeyeswithbloodandblurredvision,sometimeshaddoublevisionsandfearedoutofthelightThesignofexophthalmosesgotworseNosignsoflowfever,diarrheaandvomitingHewasadmittedtotheShimenhospitalandgottimesimpactofhormonetherapy(notclear),thenoutofhospitalwithdrugsofmethimazoleqdandvitaminBtid,butgotnoimprovementatallToseekfurthertherapy,hecametoourdepartmentdiagnosedashyperthyroidismSinceonset,hisappetitewasgood,andbothhisspiritednessandphysicalenergyarenormalDefecationandurinationareallnormalPasthistory:UlcerhistorywasreportedNohistoryofCHDNohepatitis,TBandotherinfectiousdiseaseswasreportedNoallergyhistoryoffoodormedsPersonalhistory:HewasbornandgrewupinHunanHenevergotclosetothecontaminatedwater,toxicants,orepidemicstrickenareasNosmokingoralcoholhistoryMaritalhistory:Hegotmarriedinmarriageableage,andhehasdaughterHischildrenandhiswifeareallhealthyFamilyhistory:Hisyoungbrotherhashyperthyroidism,othershealthyVitalsigns:BP:mmHgPR:bpmRR:bpmTemp:℃height:cm,weigh:kg,BMI:(kgm)HeiswelldevelopedandmoderatelynourishedHisconsciousnessisclearActivepositionNormalgaitGoodcooperationduringphysicalexaminationHehasaHyperthyroidismfaceNosignofJaundiceisnotedonhisskinandmucousmembrane,norspiderangiomataonthechestwallNosignsofenlargementofthesuperficiallymphnodesHisheadisnormocephalicThescleraisfullofbloodBilateralpupilsareroundandequalinsize,andreactivetolightandaccommodationTheshapesofthepinnaesareovalandwithnodischargesnotedNostrilsarealsosymmetricalwithnodischargeBuccalmucosaispinkishincolor,PharynxisnotcongestiveTonsilsarenotinflamedTheneckissoftJugularveinsarenotvisibleandthepulsationofcarotidarteriesisnormalStellwagsign(),Graefsign(),Mobiussign(),Jofforysign()ChestveinscouldnotbeseenIntercostalspaceisneithernarrowednorwidenedRespiratorymovementisbilaterallysymmetricThoracicexpansionandtactilefremitusaresymmetricbilaterallyNopleuralfrictionfremitusResonanceisheardduringpercussionBreathsoundsareclearNoabnormalbreathsoundisheardNoralesNobulge,noabnormalimpulseorthrillsinprecordialareaThepointofmaximumimpulseisinthleftintercostalspaceinsideofthemidclavicularlineandnotdiffuseNopericardialfrictionsoundBorderoftheheartisnormalHeartsoundsarenormalandnosplittingRateminCardiacrhythmisregularNopathologicalmurmursThereisabdominaldistensionwithpresenceofshiftingdullnessNoabdominalwallvaricosisGastralintestinaltypeorperistalsesarenotseenBorhorygmusisnormalNovascularmurmursThereisnoreboundtendernessonabdomenorrenalregionLiverandspleenisuntouchedNomassesFluidthrillisnegativeGenitourinarysystemandrectumarenotexaminedNodeformitiesofvertebralcolumnandlimbsAcropachyisnotseenJointwerenormalPhysiologicalreflexesareexistentwithoutanypathologicalonesDiagnosis:hyperthyroidismGrave’sdisease

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