ENGLISH
CASE
700756
(Respiratory department)
----------------------------------------------------------Name: Liyuzhen ` Age:42 years
Sex: Female
Race: Han
Occupation: Free occupation
Nationality: China
Married status: married
Address: Qianjing Road No.16, Wuhan Hankou.
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Date of admission: July 26 , 2001
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Date of record: July 26 , 2001
Complainer of history: Patient herself
Reliability: Reliable
----------------------------------------------------------Chief Complaint: Cough and dyspnea for 2 days.
Present illness:
Two days ago the patient suddenly started to cough and feel
dyspnea after having a bath. It became more and more serious, so
the patient went adjacent hospital. After some treatment, her
symptoms were still. So she came to our hospital. Since its coming
on, she never felt headache, nausea, bellyache and her phlegm was
few.
Her spirit,sleep,appetite were normal.stool and urine were
normal, too.
----------------------------------------------------------Past
History:
General health status: normal
Operation history: thyroidectomy.
Infection history: No history of tuberculosis or hepatitis.
Allergic history: allergic to a lot of drugs such as sulfanilamide
Traumatic history: No traumatic history
----------------------------------------------------------System
review
Respiratorysystem: No history of repeated pharyngodynia, chronic
cough, expectoration, hemoptysis, asthma, dyspnea
or chest pain.
Circulation system: No history of palpitation, hemoptysis, legs
edema, short breath after sports, hypertension,
precordium pain or faintness.
Digestive system: No history of low appetite, sour regurgitation,
belching, nausea, vomiting, abdominal distension,
abdominal pain, constipation, diarrhea, hemaptysis,
melena, hematochezia or jaundice.
Urinary system: No history of lumbago, frequency of urination,
urgency of urination, odynuria, dysuria, bloody
urine, polyuria or facial edema
Hematopoietic system: No history of acratia, dizziness, gingival
bleeding, nasal bleeding, subcutaneous bleeding
or ostealgia.
Endocrine system: No history of appetite change, sweating, chilly
excessive thirst, polyuria, hands tremor, character
alternation, obesity, emaciation, hair change, pigmentation or amenorrhea.
Kinetic system: No history of wandering arthritis, joint pain,
red swelling of joint, joint deformity, muscle pain
or myophagism.
Neural system: No history of dizziness ,headache, vertigo, insomnia, disturbance of consciousness, tremor, convulsion, paralysis or abnormal sensation.
---------------------------------------------------------Personal History:
She was born in Hubei.She never smokes and
Drinks.No exposure history to toxic substances,
and infected water.Her menstruation was normal.
LMP:23/7,2001
----------------------------------------------------------Family History:
Her parents are living and well. No congenital
disease in her family.
-----------------------------------------------------------
Physical
Examination
Vital signs: T 36.6`C , P 80/min, R 22/min, BP120/80mmHg.
General inspection: The patient is a well developed, well nou-
rished adult female apparently in no acute distress,
pleasant and cooperative.
Skin: Normally free of eruption or unusual pigmentation.
Lymphnodes: There are no swelling of lymphnodes.
Head: Normal skull. No baldness, noscars.
Eyes: No ptosis. Extraocular normal. Conjuctiva normal. The
Pupils are round, regular, and react to light and acCommodation.
Ears: Externally normal. Canals clear. The drums normal.
Nose: No abnormalities noted.
Mouth and throat: lips red, tongue red. Alveolar ridges normal.
Tonsils atrophil and uninfected.
Neck: No adenopathy. Thyroid palpable,but not enlarged. No
Abnormal pulsations. Trachea in middle.
Chest and lung: Normal contour. Breast normal. Expansion equal.
Fremitus normal. No unusual areas of dullness. Diaphr-
agmatic position and excursion normal. No abnormal breath sound. No moist rales heard. No audible pleural fricion. There are lots of rhonchi rales and whoop can be heard
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Heart: P.M.I 0.5cm to left of midolavicular line in 5 interSpace. Forceful apex beat.No thrills.No pathologic
heart murmur. Heart beat 80 and rhythm is normal.
Abdomen: Flat abdomen. Good muscle tone. No distension. No visible peristalsis. No rigidity. No mass palpable.
Tenderness (-), rebound tenderness (-).Liver and spleen
are not palpable. Shifting dullness (-). Bowl sounds
normal. Systolic blowing murmur can be heard at the
right side of the navel.
Extremities: No joint disease. Muscle strength normal. No abnormal motion. Thumb sign(+). Wrist sign(+).
Neural system: Knee jerk (-).
Achilles jerk (-).
Babinski sign (-).
Oppenheim sign (-).
Chaddock sign (-).
Conda sign (-).
Hoffmann sign (-).
Neck tetany (-)
Kernig sign (-).
Brudzinski sign (-).
Genitourinary system: Normal.
Rectum: No tenderness
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Out-patient department data:
No
-----------------------------------------------------------
History
summary
1). Li Yuzhen, female, 42y.
2). Cough and dyspnea for 2 days
3). PE: T 36.6`C, P 80/min, R 22/min, BP120/80mmHg.superficial
nodes were not palpable. Normal vision. Upper palate haunch-uped. HR: 80bpm, rhythm is normal. There are lots of rhonchi rales and whoop can be heard .Flat abdomen, Tenderness
(-),rebound tenderness (-).Liver and spleen are not palpable.Shifting dullness (-). Bowl sounds normal..
4).Outpatient data: see above.
-----------------------------------------------------------
Impression: Bronchial asthma
Signature:He Lin 95-10033