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1、MedicalRecordsforAdmissonMedicalNumber:733735GeneralinformationName:ChenDongyinAge:Forty-fourSex:FemaleRace:HanNationality:ChinaAddress:NO.11,MacaoRoad,Whhan,Hubei.Tel:8260504Occupation:PeasantMaritalstatus:MarriedDateofadmission:July6th,2002Dateofrecord:3pm,July6th,2002Complainerofhistory:th
2、epatientherselfReliability:ReliableChiefcomplaint:IntertiaandDyspepsiaforaboutdecadesdays.Presentillness:Thepatientfeltdyspepsia,intertia,nauseaandvomitingafterhertakingsometraditionalChinesemedicineorallyforherheadacheabouttendaysago.Shedidn’tgetafever.Thecolorofherurineisnormal.Thephysicale
3、xaminationshownotendernessorreboundtenderness.Thepatientwasexaminedatanotherhospital,theresultsshow“HBV(+),thefunctionoftheliverisabnormal.Sothepatientcametoourhospitalandwasacceptedas“chronichepatitisB”.Sincethediseasecomingon,thepatient’smindandappetiteisnotasgoodasnormal.Hersleeping,stoola
4、ndurinearenormalbutherphysicalstrengthisabitdecline.PasthistoryThepatientishealthybefore.Nohistoryofhepatitis.Noallergyhistoryoffoodanddrugs.PasthistoryOperativehistory:Deligationofovidutat1985.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Hewasnotallergictopenicillinor
5、sulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexce
6、ssivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryHewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas14.Lasting4dayseverytim
7、esanditscycleisabout28days.Thelatesttimewasatmarch,1999.Obstetricalhistory:Pregnacy2times,bothnatureproduction.Contraceptivehistory:Amenorrheaalready.Familyhistory:Hisparentsarebothalive.PhysicalexaminationT36.5℃,P63/min,R16/min,BP105/60mmHg.
