英文病历发热待查.doc

Name: Aiyu Sun Age: 37 Gender: Female Race: the Han nationality Birth Place: HongHu City Marital Status: Married Occupation: Farmer Address: Group Six, WeiGou Village, FengKou Town, HongHu City, Hubei Province Informant: Aiyu Sun Date of admission: June 3 , 2010 Date of history taken: June 3 , 2010 Chief Complaint: Feeling hot, palpitation, polyphagia for four months, fever for five days History of Present Illness: The patient felt hot, palpitation, polyphagia in Feburary, without obivious motivation. The symptoms appeared with shivering of hands and the head, irritability, exophthalmos of both eye balls gradually. The symptoms appeared without complaints of diarrhea, magersucht, hoarseness, blurred vision and so on. The patient did not go to receive any medical treatment. From April, the symptoms above became more severe, with powerless of limbs. The patient went to local hospital on 27th, April. Examination result: FT325pg/ml↑,FT48npg/dl↑,TSH0.01uIU/ml↓;WBC 6.11*109/L, N 7.01*109/L; ALT 52u/L↑, AST 41u/L. The patient was diagnosed as “hyperthyroidism, cacergasia of liver”. The patient took Tapazole 5mg tid , propanolol, inosine， drugs for liver protection and WBC raising from then on. The symptoms described above was relieved after taking these medicines. On 12nd, May, the bood routine was still normal: WBC 5.8*109/L, N 3.1*109/L. But five days ago, without obivious motivation, the patient had a pharynx ache, fever, which was highest at 38.7°C，with headache and catarrhus. The patient was diagnosed as “upper respiratory infection, hyperthyroidism, agranulemia” and gave antiinfection therapy. But the fever continued, the therapy effect was not well. The patient comes to our hospital today. The blood routine today is WBC 0.15*109/L↓, N0*109/L↓↓↓, and the outpatient department receives the patient to our ward as“hyperthyroidism, agranulemia”. During the course of disease, sleep and psyche were acceptable. Polyphagia lasted. Stool