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1、为了适应公司新战略的发展，保障停车场安保新项目的正常、顺利开展，特制定安保从业人员的业务技能及个人素质的培训计划病例报告英文CASEMedicalNumber:GeneralinformationName:DingZierAge:FortysevenSex:FemaleRace:HanOccupation:farmerNationality:ChinaMaritalstatus:MarriedAddress:jianlicounty，JingzhouCity,HubeiProvinceDateofadmission:April17,XXDateofrecord:April17,XXCompla
2、inerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Intermittentlowbackpainfor10yearsPresentillness:Tenyearsago,thepatientsuddenlyfeltpaininthelowerback,withhematuria,butnourinaryfrequency,urgency,dysuria,feverandothertheLeftkidneystonesremovalsurgery,Patientswithlowbackpainyearsago,pa
3、tientsfeltintermittentlowbackpainwithurinaryfrequency,urgencyagain,nodysuria,hematuria,feverandothersymptoms,thepatientdidnttreatit.XX-02-24reviewedtheultrasoundfoundthatLeftkidneystones.Forthesakeoffurthertreatment,thencometoourhospital,outpatientrevenuetoLeftkidneystonestoourdepartment.Sincetheons
4、et,thepatientsprivateprosecutionspiritedness,appetite,sleepsomewhatless,slightlymoreurination,defecationisnormal,nosignificantchangesinphysicalweight.PasthistoryOperativehistory:10yearsago,didkidneystonesremovalsurgery.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotall
5、ergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesy
6、stem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninJianliCountyandalmostalwayslivedinJianlicounty.Shedidnotgotoschool.Herlivingconditionswereingeneral.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas16.Lasting5to6dayseveryti
7、mesanditscycleisabout33days.Obstetricalhistory:Pregnacy4times,4natureproduction,noabortion.Contraceptivehistory:Notclear.Familyhistory:Herparentsarestillalive.PhysicalexaminationT,P72/min,R18/min,BP116/76mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanos
8、is.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.Respiratorymovementwasbilaterallysymmetricwiththefrequencyof18/min.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Borderoftheheart
9、wasnormal.Heartsoundswerestrongandnosplitting.Rate72/min.Cardiacrhythmwasnotregular.Nopathologicalmurmurs.Abdomenwasflatandsoft.Nobulgeordepression.Noabdominalwallvarices.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdominal.Therewasreboundtendernessonre
10、nalregion.Liverandspleenwasuntouched.Nomasses.Shiftingdullnessisnegative.Novascularmurmurs.Noedema.Physiologicalreflexeswereexistentwithoutanypathologicalones.HeadCranium:Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodisc
11、hargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasa
12、nicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Oralmucousmembranewassmooth,andofnoulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotenlarged.Neck:Symmetricandofno
13、deformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.Thorax:Symmetricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticit
14、ywasfine.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof18/min.Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecor
15、dialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate76/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Thereweretendernessandreboundtendernessonrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.
