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1、制作-丛珊珊 胡严飞 演讲：丛珊珊 胡严飞ENGLISH CASE 700756(Respiratory department)- Name: Liyuzhen Age:42 years Sex: Female Race: HanOccupation: Free occupation Nationality: ChinaMarried status: marriedAddress: Qianjing Road No.16, Wuhan Hankou.Date of admission: July 26th, 2001Date of record: July 26th, 2001Complain
2、er of history: Patient herself Reliability: Reliable-Chief Complaint(symptom/signs): Cough and dyspnea for 2 days. tomy 切开ctomy 切除术stomy 造口术 Present illness:Two days ago the patient suddenly started to cough and feel went to an adjacent deisnt adj. 邻近的hospital. After some treatment, her symptoms wer
3、e still. So she came to our hospital. Since its coming on, she never felt headache,nausean:zi恶心, bellyachebelieik 腹痛and her phlegm flem 痰was less than before.Her spirit ,sleep ,appetite were normal，stool stu:l粪便 and urine jurin尿 were normal-Past History General health status: normalOperation history
4、: thyroidectomy.甲状腺（ ）术Infection感染 history: No history of tuberculosis tju:,b:kjulusis 肺结核or hepatitis ,heptaitis肝炎Allergic l:dik 过敏history: allergic to a lot of drugs such as sulfanilamide ,slfnilmaidTraumatic history: No traumatic history-System ReviewRespiratory resprtri System: No history of rep
5、eated pharyngodynia ,fridini咽痛 chronic krnik 慢性的，长期的 cough, hemoptysis, himptisis咯血 asthma, dyspnea or chest pain.Circulation system: No history of palpitation,plpitein心悸, legs edemaidi:m, short breath after sports, hypertension高血压, precardium pri:k:dim 心前区pain or faintness feintnis晕厥.leuk（o）- 白色 me
6、lan（o）-黑色chlor（o）-绿色 erythr（o）-红色Digestivedidestiv, dai-消化 system: No history of low appetite, sour regurgitationri,:ditein回流，belchingbelti,嗳气 nausea恶心, vomitingvmiti呕吐, abdominalbdminl腹部的distensiondistenn膨胀,abdominal pain, constipationknstpe()n便秘, diarrhea腹泻, hemaptysis, melenamli:n黑便, hematochezia
7、 hi,mtuki:zi便血or jaundice. d:ndis黄疸Urinary system: No history of lumbagolmbeiu,腰痛 frequency of urination尿频, urgency of urination, odynuria尿痛, dysuria,排尿困难 bloody urine, polyuria,plijuri多尿症 or facial edemaidi:m水肿 Hematopoietic,hemtupii:tik造血system: No history of acratiakreii乏力, dizzinessdizinis眩晕, gi
8、ngivaldindaivl牙龈bleeding, nasal bleeding, subcutaneous,sbkju:teinis皮下 bleeding or stealgia,stildi.骨痛 Endocrineendukrain 内分泌system: No history of appetite change, sweatingsweti出汗, chillytili寒冷的 excessive thirst, polyuria, hands tremortrem颤抖, character alternation, obesityubi:sti肥胖, emaciationi,meisie
9、in消瘦, hair change, amenorrheaei,menri:闭经. Kinetic kinetik运动system: No history of wandering arthritis:raitis关节炎, joint关节 pain,red swelling of joint, joint deformitydfmt畸形, muscle pain .Neural system: No history of dizziness dizinis头晕,headache, vertigovtg眩晕, disturbance of consciousness, tremor, convu
10、lsionknvln 惊厥, paralysis prlisis无力or abnormal sensation.- Personal History: She was born in Hubei. She never smokes and drinks. No exposure history to toxic tksik有毒的,因中毒引起 substances, and infected water. Her menstruation menstru:en月经来潮was normal. LMP:23/7,2001- Family History: Her parents are living
11、 and well. No cogenital kndentl 先天的 disease in her family.- Physical Examination: Vital signs :T 36.6C P 80/min R 22/min BP120/80mmHg.General inspection一般检查: The patient is a well developed, well nourished nr培养 adult female apparently in no acute distress,pleasant and cooperative. Skin: Normally fre
12、e of eruptionrp()n出疹or unusual pigmentation.色素沉积Lymphnodes淋巴结 There are no swelling of lymphnodes.Head: Normal skull. No baldnessbldns光秃, no scars.Eyes: No ptosistss下垂. Extraocular ekstrkjul非凡的normal. Conjuctiva kndktaiv(眼球）结膜：normal. The pupilspju:plz 瞳孔are round, regular, and react to light and accommodation.可调节Ears: Externallyekst:nli 外表上 normal. Canals (沟渠)clear. Nose: No abnormalities noted. Mouth and throat: lips red, tongue red. Alveolar ridges 牙槽骨normal.
