




免费预览已结束,剩余1页可下载查看
下载本文档
版权说明:本文档由用户提供并上传,收益归属内容提供方,若内容存在侵权,请进行举报或认领
文档简介
_CASE Medical Number: 756943General information-可编辑修改-Name: Yue Jun-rongAge: Forty- two years oldSex: FemaleRace: HanOccupation: UnemploymentNationality: ChinaMarital status: MarriedAddress: Xiaochang county of Xiaogan city in Hubei. Tel: 4835963Date of admission: Feb.27th, 2003Date of record: 3pm, Feb.27th, 2003Complainer of history: the patient herselfReliability: ReliableChief complaint: The patient was found “myoma of uterus” over two yearsago and menometrorrhagia for 5 months.Present illness: In 1999, the patient was found “myoma of uterus” in a physical examination. But she had nothing uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness.Personal history She was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examination T 36.8, P 80/min, R 20/min, BP 120/80mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged.Head Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness. Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent. Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.Chest Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine. Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/lUrine-Rt: SG 1.070 pH 6.0B-ultrasound: 1. subserous myoma of uterus 2. position of loop is normalHepatic function: NormalPT & APTT: Normal Professional ExaminationPudendum: Married type Vagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth.Others: NormalHistory summary1. Patient was female, 45 years old2. The patient was found “myoma of uterus” over two year ago and menometrorrhagia for 5 mo
温馨提示
- 1. 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等,如果需要附件,请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸,网页内容里面会有图纸预览,若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间,仅对用户上传内容的表现方式做保护处理,对用户上传分享的文档内容本身不做任何修改或编辑,并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容,请与我们联系,我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
最新文档
- 2023年度计算机四级题库检测试题打印含完整答案详解【网校专用】
- 个人歌唱活动策划与执行要点
- 物料能量衡算精要
- 酒店微笑问好服务培训纲要
- 2026届山东省曲阜市石门山镇中学九年级化学第一学期期中学业水平测试模拟试题含解析
- 2026届山东省德州市六校化学九上期末统考模拟试题含解析
- 2026届山东滨州阳信县九年级英语第一学期期末教学质量检测模拟试题含解析
- 2026届河南省驻马店九上化学期中预测试题含解析
- 河南省南阳市宛城区等2地2025-2026学年高二上学期开学英语试题(含答案)
- 2025年腔镜技能大赛试题及答案
- JT-T-795-2011事故汽车修复技术规范
- 宁夏红墩子煤业有限公司红二煤矿环评上报版
- (高清版)DZT 0437-2023 环境地质调查规范(1:50000)
- 《压力焊方法》课件
- 2024信息安全意识培训ppt课件完整版含内容
- JGT366-2012 外墙保温用锚栓
- 《动物比较生理学》课件
- 火龙罐综合灸疗法
- 化学锚栓承载力计算
- 肺部感染性疾病课件
- 医院健康体检表
评论
0/150
提交评论