英文病历(发热待查)

Name: Aiyu Sun

Age: 37

Gen der: Female

Race: the Han n ati on ality Birth Place: H on gHu City

Marital Status: Married Occupatio n: Farmer

Address: Group Six, WeiGou Village, Fen gKou Town, Hon gHu City, Hubei Province In forma nt: Aiyu Sun

Date of admissio n: June 3,2010

Date of history take n: June 3,2010

Chief Complai nt:

Feeli ng hot, palpitati on, polyphagia for four mon ths, fever for five days

History of Prese nt Ill ness:

The patient felt hot, palpitation, polyphagia in Feburary, without obivious motivation. The symptoms appeared with shiveri ng of hands and the head, irritability, exophthalmos of both eye balls gradually. The symptoms appeared without compla ints of diarrhea, magersucht, hoarse ness, blurred visio n and so on. The patie nt did not go to receive any medical treatme nt. From April, the symptoms above became more severe, with powerless of limbs. The patie nt went to local hospital on 27th, April. Examination result: FT3>25pg/ml f ,FT4>8npg/dl f ,TSH<0.01ulU/ml J ;WBC

6.11*109/L, N

7.01*109/L; ALT 52u/L f ,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 antiinfectic therapy. But the fever con ti nu ed, the therapy effect was not well. The patie nt comes to our hospital today. The blood routine today is WBC 0.15*109/L J N0*109/L nd 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 stre ngth desce nded. Weight was stable.

Past History:

Gen eral Health Status: good V moderate poor

In fectious Disease: V no yes(if any, please write dow n date of on set, brief diag no stic and therapeutic, course ) Typhoid fever Dyse ntery Malaria Schistosomiasis Leptospirosis

Tuberculosis Epidemic hemorrhagic fever others

Allergic history: V no yes (cli nical mani festati on: allerge n: )

Trauma and/or operation history: V no yes