英文病历(发热待查).doc

Name: Aiyu SunAge: 37Gender: FemaleRace: the Han nationalityBirth Place: HongHu CityMarital Status: MarriedOccupation: Farmer Address: Group Six, WeiGou Village, FengKou Town, HongHu City, Hubei ProvinceInformant: Aiyu SunDate of admission: June 3 , 2010 Date of history taken: June 3 , 2010Chief Complaint:Feeling hot, palpitation, polyphagia for four months, fever for five daysHistory 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: FT325pg/ml,FT48npg/dl,TSH25pg/ml, FT48npg/dl, TSH25pg/ml, FT48npg/dl, TSH0.01uIU/ml;WBC 6.11*109/L, N 7.01*109/L; ALT 52u/L, AST 41u/L. 12nd, May, local hospital: Blood-rt: WBC 5.8*109/L, N 3.1*109/L;3rd, June, our hospital: Blood-rt: WBC 0.15*109/L, N 0*109/LPrimary diagnosis: 1 Hyperthyroidism 2 Agranulemia: （1）Induced by drugs； （2）Hematopoietic system diseases？(such as aplastic anemia, MDS，leukemia etc.) 3 Acute upper respiratory infection 4 Other diseases which cause fever: such as other infections, connective tissue diseases etc. Corrected diagnosis (date 2010.6.4) 1 Hyperthyroidism 2 Agranulemia: Induced by drugs 3