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1、 Complete History Name: Feng Zhichang Sex: Male Age: 76y Occupation: Retired Nationality: Han Marital status: Married Birth Place: Shanghai Address: Shanghai Date of admission: 2010/6/17, 11:08 Date of record: 2010/6/17, 15:17 Provider: Patient herself (reliable) Case History Chief Complaints: Blood
2、 glucose increased for 15 years, dizziness and vomiting for 4 days. Present illness The patient was found urine glucose negative in examination 15 years ago. Fasting blood sugar was 14 mmol/L without polydipsia, polyuria, polyphagia and obvious marasmus. He went to see the doctor in local hospital a
3、nd was confirmed that he had type 2 diabetes. The patient received anti-diabetic medications, 5pills, tid. Fasting blood sugar was controlled about 5 mmol/L. Postprandial blood sugar was controlled 7 to 8 mmol/L. From 10 years ago, because the blood sugar was out of control, fasting blood sugar was
4、12 to 13 mmol/L, The patient received Acarbose, 1 pill, tid for replacement, increased Glucophage, 1 pill, tid, 5 years ago. Changed to Diamicron, 1 pill, bid and Acarbose, 1 pill, tid, 4 years ago, and fasting blood sugar was 5 to 6 mmol/L, postprandial blood sugar was 7 to 8 mmol/L. Half a year ag
5、o, the patient received Diamicron retard tablets, 1 pill, qd and Acarbose, 1 pill, tid, fasting blood sugar was 6 to 8 mmol/L, postprandial blood sugar was 8 to 13 mmol/L. August 2007, The patient felt dizziness with nausea, no vomiting and vertigo, last about 5 minutes. The syndrome easily appeared
6、 after sweating and exercise. The doctor in Zhongshan hospital thought it was lack of brain blood supply. After using Kaishi, the syndromes disappeared. 13 June this year, the patient felt dizziness again with nausea and vomiting, no vertigo sweating. The BP was 160/100mmHg, finger tip blood glucose
7、: 17mmol/L. After using Kaishi in emergency room, the patient gets better. He was admitted to hospital for further treatment. During the course of the disease, the patient felt visual disturbance, frequency of nycturia increased for 1 to 2 years, and the feet felt numbness for 2 to 3 months. General
8、 status is normal. Spirit, sleep, appetite are normal. Stool, urine are normal. No obviously change in weight. Past Medical History Chronic disease history: NO hypertension and CHD. Has a history of lacunar infarction. Operation and traumatic history: No history of big operation, a history of battle
9、 injury Infection history: No history of tuberculosis or hepatitis. Allergic history: penicillin Blood Transfusion history: No blood transfusion history. Review of System Respiratory system: No history of cough, expectoration, hemoptysis, ague, fever or dyspnea. Circulation system: No history of ede
10、ma or oliguria. Digestive system: No history of sour regurgitation, belching, nausea, vomiting, abdominal, abdominal pain, constipation, diarrhea, hemaptysis, melena, hematochezia or jaundice. Urinary system: No history of disuria, frequency of urination, urgency of urination, odynuria or facial ede
11、ma. Hematopoietic system: No history of acratia, dizziness, gingival bleeding, nasal bleeding, subcutaneous bleeding or ostealgia. Endocrine system: Please refer to present history. Kinetic system: No history of wandering arthritis, joint pain, red swelling of joint, joint deformity, muscle pain or
12、myophagism. Neural system: No history of dizziness, headache, vertigo, in-somnia, disturbance of consciousness, tremor, convulsion, paralysis or abnormal sensation. Personal History The patient was born in Shangdong. Has a army history. He has ever gone to Fujian and North Korea. Now he lives in Sha
13、nghai. He has a history of smoking and drinking and now has given up them. No exposure history to epidemic area of infectious disease. Marital History Married Family History His parents are living and well. No inherited disease or infection disease in his family. Physical Examination T: 36.7, P: 80/
14、min, R: 20/min, BP: 140/80mmHg. Natural good erect posture. Well developed. Moderate nourished. Natural facial expression. Clear and cooperative in mentality. Regular respirations. No jaundice or rashes. No cyanosis and bruises. No liver palm or spider angioma. No enlarged lymph nodes. The shape of
15、head is normal. No sclera jaundice. No edema in eye-lips, no ptosis, no congestion. The pupils are round and equal, reactive well to light and accommodation. Hearing good in both ears. No abnormal pinnae. The external canals are clear without pus. No tenderness over the mastoids. The nose showed no
16、deformity. No discharge. There is no deviation of the septum. No tenderness over the sinuses. The lips are red, the tongue is normal. No injection on the pharynx. The tonsils are not enlarged. The neck is supple. The thyroid is not enlarged. The trachea is in the middle line. Contour is normal. No sternum tenderness. Lungs field clear to percussion without dullness or hyper-resonance. Breathin
