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1、CASEMedicalNumber:682786GeneralinformationName:WangRunzhenAge:FortythreeSex:FemaleRace:HanOccupation:TeacherNationality:ChinaMaritalstatus:MarriedAddress:NO.38,HangkongRoad,JiefangRvenue,Hankou,Hubei.Tel:82422500Dateofadmission:Jan11st,2001Dateofrecord:11Am,Jan11st,2001Complainerofhi
2、story:thepatientherselfReliability:ReliableChiefcomplaint:Rightbreastmassfoundformorethanhalfamonth.Presentillness:Halfamonthago,thepatientsuddenlyfeltpaininherrightchestwhensheputupherhand.Aftertouchingit,shefoundamassinherrightbreast,butnotendness,andthepatientdidn’tpayattentionit.
3、Thenthepainbecamemoreandmoreserious,sothepatientwenttotumourhospitalandreceivedapathologycentesis.Herdiagnosiswasbreastcancer.Thenshecametoourhospitalandaskedforanoperation.Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,
4、too.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohis
5、toryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.Personalhistory
6、ShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas14.Lasting3to4dayseverytimesanditscycleisabout30days.Obstetricalhistory:Pregnacy3times,oncenatu
7、reproduction,abortiontwice.Contraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdied.PhysicalexaminationT36.4℃,P80/min,R20/min,BP90/60mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiom
8、awasnotseen.
