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1、 ENGLISH CASE 700756 (Respiratory department) - Name: Liyuzhen Age:42 years Sex: Female Race: Han Occupation: Free occupation Nationality: China Married status: married Address: Qianjing Road No.16, Wuhan Hankou. Date of admission: July 26th, 2001 Date of record: July 26th, 2001 Complainer of histor
2、y: Patient herself Reliability: Reliable - Chief Complaint: Cough and dyspnea for 2 days. Present illness: Two days ago the patient suddenly started to cough and feel dyspnea after having a bath. It became more and more serious, so the patient went adjacent hospital. After some treatment, her sympto
3、ms were still. So she came to our hospital. Since its coming on, she never felt headache, nausea, bellyache and her phlegm was few. Her spirit,sleep,appetite were normal.stool and urine were normal, too. - Past History: General health status: normal Operation history: thyroidectomy. Infection histor
4、y: No history of tuberculosis or hepatitis. Allergic history: allergic to a lot of drugs such as sulfanilamide Traumatic history: No traumatic history - System review Respiratorysystem: No history of repeated pharyngodynia, chronic cough, expectoration, hemoptysis, asthma, dyspnea or chest pain. Cir
5、culation system: No history of palpitation, hemoptysis, legs edema, short breath after sports, hypertension, precordium pain or faintness. Digestive system: No history of low appetite, sour regurgitation, belching, nausea, vomiting, abdominal distension, abdominal pain, constipation, diarrhea, hemap
6、tysis, melena, hematochezia or jaundice. Urinary system: No history of lumbago, frequency of urination, urgency of urination, odynuria, dysuria, bloody urine, polyuria or facial edema Hematopoietic system: No history of acratia, dizziness, gingival bleeding, nasal bleeding, subcutaneous bleeding or
7、ostealgia. Endocrine system: No history of appetite change, sweating, chilly excessive thirst, polyuria, hands tremor, character alternation, obesity, emaciation, hair change, pig- mentation or amenorrhea. Kinetic system: No history of wandering arthritis, joint pain, red swelling of joint, joint de
8、formity, muscle pain or myophagism. Neural system: No history of dizziness ,headache, vertigo, in- somnia, disturbance of consciousness, tremor, conv- ulsion, paralysis or abnormal sensation. - Personal History: She was born in Hubei.She never smokes and Drinks.No exposure history to toxic substance
9、s, and infected water.Her menstruation was normal. LMP:23/7,2001 - Family History: Her parents are living and well. No congenital disease in her family. - Physical Examination Vital signs: T 36.6C , P 80/min, R 22/min, BP120/80mmHg. General inspection: The patient is a well developed, well nou- rish
10、ed adult female apparently in no acute distress, pleasant and cooperative. Skin: Normally free of eruption or unusual pigmentation. Lymphnodes: There are no swelling of lymphnodes. Head: Normal skull. No baldness, noscars. Eyes: No ptosis. Extraocular normal. Conjuctiva normal. The Pupils are round, regular, and react to light and ac- Commodation. Ears: Externally normal. Canals clear. The drums normal. Nose: No abnormalities noted. Mouth and throat: lips red, tongue red. Alveolar ridges normal. Tonsils atrophil and uninfected. Ne
