问诊练习版11CM Complete Case Report (2).doc

A Complete Case Report Name Occupation Age Address Gender Date of admission Nationality Date of recording Birthplace Person providing history Marital state ReliabilityChief Complaint (CC.): symptoms ( or signs) + durationPresent History (PH.): onset, characteristics of main symptoms ( site nature what aggravates what relieves radiation ever had it before), inducing factors and causes, changes of the main symptoms, associated symptoms, medication, general circumstances.Past medical history: The past healthy state, previous diseases or problems related to underling present illness (including previous episodes e.g. angina and myocardial infarction, infectious diseases such as hepatitis, pulmonary tuberculosis, hypertension, diabetes), surgical history, preventive inoculation, allergic (including drug and food allergy) history.Review of systemsRespiratory system: chest pain, shortness of breath, wheezing, dyspnea, nocturnal dyspnea, orthopnea, cough, sputum, hemoptysis, night sweats, fevers, pleurisy, bronchitis, tuberculosis ( history of contacts), pneumonia, asthma, other respiratory infection.Cardiovascular system: palpitation, chest pain, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cyanosis, edema; intermittent claudication, cold extremities, thromboses, postural or permanent changes in skin color; hypertension, rheumatic fever, chorea, syphilis, diphtheria; drugs such as digitalis, quinidine, nitroglycerin, diuretics, anticoagulants, antiplatelet agents, and other medicationsGastrointestinal system: appetite, changes in weight, dysphagia, nausea, eructation, flatulence, vomiting, hematemesis, abdominal pain or colic, diarrhea, hemorrhoids, change in bowel habits, jaundice. Genitourinary system: color of urine, polyuria, oliguria, nocturia, dysuria, hematuria, pyuria, urinary retention, urinary frequency, incontinence, pain or colic, passage of stones or gravel, edema, venereal disease history, drugs or history of contact with lead, mercury,etc. Hemopoietic system: pallor fatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxis, history of contact with chemical products, industrial poison or radioactive substance, etc.Endocrine system: history of growth, body configuration, and weight ; size of hands, feet, and head, especially changes during adulthood; hair distribution; skin pigmentation; goiter, exophthalmos, dryness of skin and hair, intolerance to heat or cold, tremor; polyphagia, polydipsia, polyuria, glycosuria; secondary sex characteristics, impotence, sterility, treatment.Nervous system: dizziness, headache, vertigo, syncope, degeneration of memory, visual disturbance, insomnia, disturbance of consciousness, tremor, spasm, paralysis, paresthesia,Psychiatric history: Describe difficulties with interpersonal relationships ( with parents, siblings, spouse, children, friends and associates), sexual adjustments, employment success and difficulties, impulse control, sleep disorders, mood swings, difficulty with concentration, thought or the presence of hallucinations.Bones, Joints, and Muscles:Fractures, dislocations, sprains, arthritis, myositis, pain, swelling, stiffness, migratory distribution, degree of disability, muscular weakness, wasting, or atrophy, night cramps.Personal history: birthplace and resident place, occupation, sexual history, smoking, alcohol intake. Marital history: marrying age , companions state of health. Menstruation and Childbearing history: menarche age lasting days date of last period（age cycle of menopause）,the amount of flow, menstrual pain, cycle: regular or irregular, pregnancy: natural labor, abortions, premature delivery, stillbirths, difficult labor and its condition.Family history: pay attention to the congenital diseases and communicable diseases related to the patient.Physical Examination T P R BP General Appearance: development, habitus, nutrition (well nourished, moderately nourished, poorly nourished), facial characteristics ( quiet, acute, chronic, anemia, jaundice, cyanotic, etc.), position ( active, passive, compulsive) and gait, conciousness ( clear and co-operative in mentality, loss of consciousness- somnolence, confusion, stupor, coma).Skin: color (lustrously rich, pallor, redness, cyanotic, jaundice, pigmentation), moisture (sweating or dry), temperature (warm or cold) , elasticity, skin eruption, subcutaneous hemorrhage ( petechia, purpura, ecchymosis, hematoma), subcutaneous nodules, spider angioma and liver palm, hair distribution, edema. (site, pitting or non-pitting, severity- slight, moderate, severe).Lymph Nodes: preauricular, retroauricular, occipital, submaxillary, submental, anterior cervical, posterior cervical, supraclavicular, axillary ( apical, central, pectoral, subscapular, lateral nodes), supratrochlear, inguinal ( superior, inferior nodes), popliteal. Note number, site, size, consistency, surface, mobility, tenderness, warmth, whether discrete or matted together, whether fixation to superficial and other surrounding tissues.HeadSkull: development, deformities, scars, masses, retraction or tenderness. Hair color, distribution. Eyes: Eyebrows (normal, sparse or loss). Eyelids ( entropion or extropion, ptosis, lid retraction, edema). Conjunctivae ( pallor, congestion, redness and swelling, jaundice, petechiae, granules and follicles, edema) slight . Eyeballs (position, shape, movement). Note exophthalmos or enophthalmos, diplopia, and nystagmus. Cornea ( clear and transparent, nebula, leukoplakia, softness, ulcerative, neovascularization). Sclera (Note jaundice). Iris. Lens. Pupils (size, symmetry, irregularity and response to light including direct response to light, consensual reflex, near reflex).Ears: Auricle (Note shape, size, site, symmetry, deformities). External auditory meatus (abnormal discharge). Auricular acuity.Nose: Note deformities, nasal ale flap, distortion in nasal septum, abnormal discharge. Note tenderness over paranasal sinuses.Mouth Cavity: Lips (pallor, cyanotic, pigmentation, vesicles). Buccal mucosa (hemorrhage and ulceration, petechiae, pigmentation, neoplasm, Koplik spots, opening of parotid duct). Gum (pink, pallor, hypertrophy, hemorrhage). Tongue (color, position, and movement).Teeth ( arrangement, caries, ill-fitting dentures). Tonsils ( Note hyperplasia, ulcers, exudates, masses). Posterior pharyngeal wall （congestion, redness and swelling, exudates）. Voice.Neck: Neck (soft and supple or rigid, posture, deformities). Skin ( Note spider angioma, infection, scar, fistulas, masses). Arterial and venous pulsation. Jugular venous engorgement. Thyroid gland ( Inspection, palpation, auscultation).Trachea ( position ).Chest: Topography (normal , barrel chest, flat chest, pigeon chest, funnel chest, bulging or retraction bulging in the precordial region) , skin, subcutaneous emphysema, tenderness of sternum. Breast (normal symmetrical, gynecomastia, mass, tenderness, excretions of nipples).Lung:Inspection: Movement of respiration (normal, increased or decreased). Intercostals space (normal or abnormal: wide, or narrow- position ).Palpation: Thoracic expansion, Vocal fremitus ( normal, increased decreased) . Pleural friction rubs: (position ).Percussion: Normal: resonance , abnormal: dullness , flatness, hyperresonance, tympany. Lower borders: midclavicular line, midaxillary line, scapular line- note intercostals space on right and left side. Range of mobility: right cm, left cm. Auscultation: Breath sound: normal, or abnormal (feature, position) . Rales: ronchi- sonorous , sibilant; moist rales- coarse, medium, fine rales, crepitus. Vocal conduction: normal, abnormal: reduced or increased. Pleural friction rubs: (position ).Heart:Inspection: shape of the chest wall, esp. precordial bulge, apex beat, abnormal pulsation.Palpation: confirm the position of apical impulse found by inspection, thrill, pericardial friction.Percussion: Identify the cardiac dullness area. Normal cardiac dullness area: Right (cm) Intercostals Left (cm)2-3 2-32-3 3.5-4.53-4 5-6 7-9* The distance from the left midclavicular line to the midsternal line: 8-10cmAuscultation: Heart rate, Heart rhythm: regular or irregular, Heart sound: S1, S2, S3, S4; Heart soundor ; Splitting of the heart sound, Additional heart sound: gallop(early diastolic gallop- pathological S3, late diastolic gallop- pathological S4), opening snap, mid and late systolic click. Murmur. Pericardial friction sound.Peripheral vessels: normal pistol shot, Duroziez sign, water hammer pulse, capillary pulsation, pulse deficit, paradoxical pulse, pulsus alternans.Abdoman： Inspection: shape ( normal, distention, frog belly, scaphoid abdomen apical belly), gastric pattern or intestinal pattern, peristalsis, abdominal respiration, umbilicus, others(venous distention of abdomen, purple striae, surgical scars, hernia). Palpation: soft, muscle tension , tenderness (e.g. tenderness of gallbladder, McBurney tenderness) or rebound tenderness, fluid thrill, succusion splash, masses: description of feature(site, size, contour, consistency, tenderness, pulsation, mobility, fixation ), liver, gallbladder,Murphys sign, spleen, kidney , tenderness of ureters.Percussion: borders of liver dullness , upper border of liver, shifting dullness, punch tenderness over the liver, spleen and renal region.Auscultation: gurgling sound, vessel bruits. Genitalia: not examined normal abnormal.Rectum and Anus: not examined normal abnormal:Spine and Extremities: spine: normal deformities (lateral anterior posterior protruding), acanthi: tenderness mobility: normal restrictedlimbs: normal abnormal deformity swelling of joints joints stiffness tenderness of muscles. atrophy of muscles venous distention of lower limbs(position and feature ) acropachy.Nervous System:Muscle tone (normal increase decrease paratonia) , myodynamia（0 I II III IV V）. paralysis of limbs. Reflex: corneal reflex, abdominal wall reflex , biceps reflex, triceps reflex, patellar reflex, achilles reflex. Hoffmann sign. Babinski sign, Oppenheim sign, Gordon sign, Kernig sign, Brudzinski sign.Laboratory FindingsRecord the results of the initial laboratory which you have used to assist in the development of your differential diagnosis.Case Summary After recording the history and physical examination, analyze the chronology, symptoms, signs, and laboratory findings of the illness. It is advisable to write a brief summary of your findings as an abstract of the significant observations.Primary Diagnosis:Diagnostic evidence:Differential diagnosis:Treatment plan: Signature: A Complete Case ReportName: YangSex: FemaleAge: 30years oldMarital Status: MarriedBirth Place: GuangzhowNation: HanOccupation: PeasantAddress: The Third Group, ZhaoYang Country, Huang Pu District, Guangzhow.Sources: The patientReliability: ReliableDate of Admission: 9:00AM Oct.15 1996Date of History Recording: 3:00PM Oct.15 1996Chief Complaint: A ten-year history of exertional palpitation and shortness of breath accompanied by ankle swelling for one week.Present History: From 1986, the patient felt palpitation and shortness of breath after rapid walking, riding or exertion. The symptoms would relieved after taking a rest. She had ever gone to the First Affiliated Hospital of Guangzhow Medical College and was found that there was cardiac murmurs. However, the above manifestations were not so serious that no systemic treatments were given. She went to work as usual. From 1992, she had shortness of breath when climbing three floors every day, but was capable of doing housework. Therefore, she did not take it seriously. However, her palpitation and shortness of breath occurred again and became more severe accompanied by cough with bloody sputum until 1995- after overwork of cleaning the house for Spring Festival. She was admitted to the near Zhao Yang Hospital immediately. By given penicillin 、glucose intravenously and antibechic orally, she felt comfortable gradually while the doses of medications were not known. She was discharged from the hospital two weeks later when all symptoms had disappeared. The diagnoses made by that hospital were Rheumatic valvular heart disease, mitral stenosis. Since then , the patient went to the clinic in Zhao Yang Hospital or the First Affiliated Hospital of Guangzhow Medical College for consultation now and then and took “diuretics heart protective drugs . The exact names and doses of these drugs were not clear. She felt better than before. One week ago, the patient had cough with a large amount of white frothy sputum and occasional flecks of blood, associated with obvious palpitation, shortness of breath only after slight activities, difficulties in lying flat and ankle swelling of both sides after getting cold. She took the above drugs prescribed by the clinic doctors but without any improvements. Therefore, she was admitted to our hospital today for further diagnosis and treatment. From this attack, she had fever with the maximal body temperature reaching 38.7 accompanied by a lot of amount of sweating, generalized somatalgia, but no chill, no migrating sore joints. Besides, she had upper abdominal distension and loss of appetite. Urine output diminished and urine color became darken. Passing bowels was once two days and the stools were normal in shape. The patient had not taken digitalis during this week. Past Medical History: The patient has been weak all the time. When she was young, she often suffer from sore throat. No history of infectious diseases such as hepatitis, tuberculosis had been found. The preventive inoculation was on time. No known allergic history of drugs or foods. She had no experiences of operation and trauma.Review of Systems:Respiratory System: She often had sore throat when she was young. In each attack she felt something in her throat and accompanied by fever. These problems could be solved by using antibiotics for several days. No chronic cough, expectoration and hemoptysis. No asthma. No chest pain.Circulatory System: See the above present illness history. No history of hypertension and syncope.Digestive System: No reflux of gastric acid , eructation, vomiting, abdominal pain, diarrhea, constipation, jaundice, hematemesis, hematochezia and melena. Urinary System: No loin pain, No urgent, frequent and painful urination. No dysuria, hematuria, nocturia and change urine volume. No history of contact with lead, ,mercury, etc.Hemopoietic System: No gingival hemorrhage, epistaxis, subcutaneous bleeding and bone pain. No history of contact with chemical products, industrial poison or radioactive substance, etc.Endocrine System: No increased appetite, emotionally labile, weight loss and tremor. No polydipsia, polyuria, No abnormal loss or growth of hair. No skin pigmentation. No sexual dysfunction.Bones, Joints and Muscles: No migrating arthritis. No joint deformities, myalgia and muscular atrophy.Nervous system:She had occational dizziness and headache, but no vertigo and syncope attack. No loss of conciousness tic or convulsion. No sensory abnormalities, visual disorders and memory problems.Personal History: She was born and developed in birth place. She had been working as a peasant all the time. She had not ever been to other places. No history of contact with contaminated water. Her residence was not infectious or epidemic area. After graduated from a middle school, she had not received any further education. She was quite in character and did not drink or smoke. Her husband and her denied either having illicit sexual relationship or contacting venereal diseases.Marital History: She got married 6 years ago. Her husband was 33 years old and in good health. Their relationship was quite well.Menstrual and Child-bearing History: Her menarche started at the age of fourteen with periods of every twenty-four, lasting four to six days. (14 4-6 1996.10.5). She had no history of blood 24 clot or dysmenorrheal. Menstrual period was regular. No leukorrhagia and no abnormal odor. She had not have pregnancy yet due to contraception after marriage.Family History: Her parents were sound. She had one younger brother and one younger sister. Both of them were health. She denied family history of the similar disorders, psychosis or hereditary diseases.Physical Examination: T 38 P 83beats/min R 22times/min BP 120/80mmHgGeneral Appearance: Well developed. Moderately nourished. Chronic and tired facial expression with lethargy. Shortness of breath in a semi-supination position. Clear and co-operative in mentality.Skin: Lustrously rich. No obvious jaundice. No petechia and ecchymosis. No erythema marginatium and subcutaneous nodules. No spider angioma and liver palm. Normal hair distribution. Body skin temperature warm but the extremities cold. Normal moisture and good elasticity. Pitting edema present below ankle joints.Lymph Nodes: In left and right submandibular regions, one lymph node , 1.0cm in diameter, soft and mobile with slight tenderness, palpated respectively. No enlargement of lymph nodes found in the other superficial areas of the body.Head:Skull: Normally develope