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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,Jan11
2、st,2001Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Rightbreastmassfoundformorethanhalfamonth.Presentillness:Halfamonthago,thepatientsuddenlyfeltpaininherrightchestwhensheputupherhand.Aftertouchingit,shefoundamassinherrightbreast,butnot
3、endness,andthepatientdidn’tpayattentionit.Thenthepainbecamemoreandmoreserious,sothepatientwenttotumourhospitalandreceivedapathologycentesis.Herdiagnosiswasbreastcancer.Thenshecametoourhospitalandaskedforanoperation.Sinceonset,herappetitewasgood,andbothherspirited
4、nessandphysicalenergyarenormal.Defecationandurinationarenormal,too.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofr
5、espiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweat
6、s.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrua
7、lhistory:Thefirsttimewhenshewas14.Lasting3to4dayseverytimesanditscycleisabout30days.Obstetricalhistory:Pregnacy3times,oncenatureproduction,abortiontwice.Contraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdied.PhysicalexaminationT36.4℃,P80/min,R20/min,B
8、P90/60mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.
