血液科英文病历

Medical Records for Admisson Medical Number: 696235 General information Name:Yu Xinwen Age: 50 Sex: male Race:Han Nationality:China Address: Shimen town,Changde city, Hunan province Date of admission: 15:20, April 1st, 2015 Date of record: 16:00, April 1st, 2015 Complainer of history: Yu Xinwen Reliability: Reliable Chief complaint: Palpitation and tremor of hands for 1 year, and blurred vision, photophobia and tears for 5 months. Present illness: The patient felt palpitation and tremor of hands in April, 2015, accompanied by the symptom of fatigue. No signs of fever, diarrhea and exophthalmoses. He came to the local hospital and received the related therapy (not clear), diagnosed as hyperthyroidism, but did not get significantly better. In August, the patient began to tear out of control, but did not receive any treatment. In October, he had swelling of the eyes with blood and blurred vision, sometimes had double visions and feared out of the light. The sign of exophthalmoses got worse. No signs of low fever, diarrhea and vomiting. He was admitted to the Shimen hospital and got 3 times impact of hormone therapy (not clear), then out of hospital with drugs of methimazole qd and vitaminB4 tid, but got no improvement at all. To seek further therapy, he came to our department diagnosed as hyperthyroidism. Since onset, his appetite was good, and both his spiritedness and physical energy are normal. Defecation and urination are all normal. Past history: Ulcer history was reported. No history of CHD. No hepatitis, TB and other infectious diseases was reported. No allergy history of food or meds. Personal history: He was born and grew up in Hunan. He never got close to the contaminated water, toxicants, or epidemic-stricken areas. No smoking or alcohol history. Marital history: He got married in marriageable age, and he has 1 daughter. His children and his wife are all healthy. Family history: His young brother has hyperthyroidism, others healthy. Vital signs: BP:110/70mmHg PR:70bpm RR:20bpm Temp:36.8℃height: 165cm, weigh: 60kg, BMI: 22.0(kg/m2) He is well developed and moderately nourished. His consciousness is clear. Active position. Normal gait. Good cooperation during physical examination. He has a Hyperthyroidism face. No sign of Jaundice is noted on his skin and mucous membrane, nor spider angiomata on the chest wall. No signs of enlargement of the superficial lymph nodes. His head is normocephalic. The sclera is full of blood. Bilateral pupils are round and equal in size, and reactive to light and accommodation. The shapes of the pinnaes are oval and with no discharges noted. Nostrils are also symmetrical with no discharge. Buccal mucosa is pinkish in color,Pharynx is not congestive. Tonsils are not inflamed. The neck is soft. Jugular veins are not visible and the pulsation of carotid arteries is normal. Stellwag sign (+), Graef sign (+), Mobius sign (+), Joffory sign (+). Chest veins could not be seen. Intercostal space is neither narrowed nor widened. Respiratory movement is bilaterally symmetric. Thoracic expansion and tactile fremitus are symmetric bilaterally. No pleural friction fremitus. Resonance is heard during percussion. Breath sounds are clear. No abnormal breath sound is heard. No rales. No bulge, no abnormal impulse or thrills in precordial area. The point of maximum impulse is in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart is normal. Heart sounds are normal and no splitting. Rate 74/min. Cardiac rhythm is regular. No pathological murmurs. There is abdominal distension with presence of shifting dullness. No abdominal wall varicosis. Gastralintestinal type or peristalses are not seen. Borhorygmus is normal. No vascular murmurs. There is no rebound tenderness on abdomen or renal region. Liver and spleen is untouched. No masses. Fluidthrill is negative. Genitourinary system and rectum are not examined. No deformities of vertebral column and limbs. Acropachy is not seen. Joint were normal. Physiological reflexes are existent without any pathological ones. Diagnosis: hyperthyroidism Grave’s disease