英文病历(发热待查)

Name: Aiyu Sun

Age: 37

Gender: Female

Race: the Han nationality

Birth Place: HongHu City

Marital Status: Married

Occupation: Farmer

Address: Group Six, WeiGou Village, FengKou Town, HongHu City, Hubei Province Informant: Aiyu Sun

Date of admission: June 3 , 2010

Date of history taken: June 3 , 2010

Chief Complaint:

Feeling hot, palpitation, polyphagia for four months, fever for five days

History of Present Illness:

The patient felt hot, palpitation, polyphagia in Feburary, without obivious motivation. The symptoms appeared with shivering of hands and the head, irritability, exophthalmos of both eye balls gradually. The symptoms appeared without complaints of diarrhea, magersucht, hoarseness, blurred vision and so on. The patient did not go to receive any medical treatment. From April, the symptoms above became more severe, with powerless of limbs. The patient went to local hospital on 27th, April. Examination result: FT3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC 6.11*109/L, N 7.01*109/L; ALT 52u/L↑, AST 41u/L. The patient was diagnosed as “hyperthyroidism, cacergasia of liver”. The patient took Tapazole 5mg tid , propanolol, inosine，drugs for liver protection and WBC raising from then on. The symptoms described above was relieved after taking these medicines. On 12nd, May, the bood routine was still normal: WBC 5.8*109/L, N 3.1*109/L. But five days ago, without obivious motivation, the patient had a pharynx ache, fever, which was highest at 38.7°C，with headache and catarrhus. The patient was diagnosed as “upper respiratory infection, hyperthyroidism, agranulemia” and gave antiinfection therapy. But the fever continued, the therapy effect was not well. The patient comes to our hospital today. The blood routine today is WBC 0.15*109/L↓, N0*109/L↓↓↓, and the outpatient department receives the patient to our ward as“hyperthyroidism, agranulemia”.

During the course of disease, sleep and psyche were acceptable. Polyphagia lasted. Stool and urine were as usual. Physical strength descended. Weight was stable.

Past History:

General Health Status: good √moderate poor

Infectious Disease: √no yes(if any, please write down date of onset, brief diagnostic and therapeutic, course )

Typhoid fever Dysentery Malaria Schistosomiasis Leptospirosis Tuberculosis Epidemic hemorrhagic fever others

Allergic history: √no yes (clinical manifestation: allergen: ) Trauma and/or operation history: √no yes

Review of Symptoms:

Respiratory system: √no yes

Repeated pharyngeal pain:chronic cough: expectoration: Hemoptysis: asthma: dyspnea: chest pain:

Circulatory system:√no yes

Palpitation: exertional dyspnea: cyanosis: hemoptysis: Edema of lower extremities: chest pain: syncope: hypertension:

Digestive system:√no yes

Anorexia: dysphagia: sour regurgitation: eructation: nausea: Emesis: melena: abdominal pain: diarrhea: hematemesis: Hematochezia: jaundice:

Urinary system:√no yes

Lumbar pain: urinary frequency: urinary urgency: dysuria: oliguria: Polyuria: retention of urine: incontinence of urine: hematuria: Pyuria: nocturia: puffy face:

Hematopoietic system:√no yes

Fatigue: dizziness: gingival hemorrhage: epistaxis: subcutaneous hemorrhage:

Metabolic and endocrine system:√no yes

Bulimia: anorexia: hot intolerance: hyperhidrosis: cold intolerance: Polydipsia: amenorrhea: tremor of hands: character change: Marked obesity: marked emaciation: hirsutism: alopecia: Hyperpigmentation: sexual function change: impotence: amenorrhea:

Musculoskeletal system:√no yes

Migrating arthralgia: arthralgia: artrcocele: arthremia: Dysarthrosis: myalgia: muscular atrophy:

Neurological system:√no yes

Dizziness: headache: paresthesia: hypomnesis: Visual disturbance: Insomnia: somnolence: syncope: convulsion:

Disturbance of consciousness: paralysis: vertigo:

Personal history:

Resident history in endemic disease area:√no yes

Smoking: √no yes: about___years

Drinking:√no occasional frequent: about____years average____ml/day Others: