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1、Name:AiyuSunAge:37Gender:FemaleRace:theHannationalityBirthPlace:HongHuCityMaritalStatus:MarriedOccupation:FarmerAddress:GroupSix,WeiGouVillage,FengKouTown,HongHuCity,HubeiProvinceInformant:AiyuSunDateofadmission:June3,2010Dateofhistorytaken:June3,2010ChiefComplaint:Feelinghot,palpitat
2、ion,polyphagiaforfourmonths,feverforfivedaysHistoryofPresentIllness:Thepatientfelthot,palpitation,polyphagiainFeburary,withoutobiviousmotivation.Thesymptomsappearedwithshiveringofhandsandthehead,irritability,exophthalmosofbotheyeballsgradually.Thesymptomsappearedwithoutcomplaintsofdia
3、rrhea,magersucht,hoarseness,blurredvisionandsoon.Thepatientdidnotgotoreceiveanymedicaltreatment.FromApril,thesymptomsabovebecamemoresevere,withpowerlessoflimbs.Thepatientwenttolocalhospitalon27th,April.Examinationresult:FT3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC6.11*109/L,N7.01*109
4、/L;ALT52u/L↑,AST41u/L.Thepatientwasdiagnosedas“hyperthyroidism,cacergasiaofliver”.ThepatienttookTapazole5mgtid,propanolol,inosine，drugsforliverprotectionandWBCraisingfromthenon.Thesymptomsdescribedabovewasrelievedaftertakingthesemedicines.On12nd,May,theboodroutinewasstillnormal:WBC5.8
5、*109/L,N3.1*109/L.Butfivedaysago,withoutobiviousmotivation,thepatienthadapharynxache,fever,whichwashighestat38.7°C，withheadacheandcatarrhus.Thepatientwasdiagnosedas“upperrespiratoryinfection,hyperthyroidism,agranulemia”andgaveantiinfectiontherapy.Butthefevercontinued,thetherapyeffectw
6、asnotwell.Thepatientcomestoourhospitaltoday.ThebloodroutinetodayisWBC0.15*109/L↓,N0*109/L↓↓↓,andtheoutpatientdepartmentreceivesthepatienttoourwardas“hyperthyroidism,agranulemia”.Duringthecourseofdisease,sleepandpsychewereacceptable.Polyphagialasted.Stoolandurinewereasusual.Physicalstr
7、engthdescended.Weightwasstable.PastHistory:GeneralHealthStatus:good√moderatepoorInfectiousDisease:√noyes(ifany,pleasewritedowndateofonset,briefdiagnosticandtherapeutic,course)TyphoidfeverDysenteryMalariaSchistosomiasisLeptospirosisTuberculosisEpidemichemorrhagicfeverothersAllergichist
8、ory:√
