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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,
2、Jan11st,2001Complainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Rightbreastmassfoundformorethanhalfamonth.Presentillness:Halfamonthago,thepatientsuddenlyfeltpaininherrightchestwhensheputupherhand.Aftertouchingit,shefoundamassinherrightbre
3、ast,butnotendness,andthepatientdidn’tpayattentionit.Thenthepainbecamemoreandmoreserious,sothepatientwenttotumourhospitalandreceivedapathologycentesis.Herdiagnosiswasbreastcancer.Thenshecametoourhospitalandaskedforanoperation.Sinceonset,herappetitewasgood,and
4、bothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,too.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respirator
5、ysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noac
6、romegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadper
7、sonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas14.Lasting3to4dayseverytimesanditscycleisabout30days.Obstetricalhistory:Pregnacy3times,oncenatureproduction,abortiontwice.Contraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdied.Physical
8、examinationT36.4℃,P80/min,R20/min,BP90/60mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.
