资源预览内容
第1页 / 共17页
第2页 / 共17页
第3页 / 共17页
第4页 / 共17页
第5页 / 共17页
第6页 / 共17页
第7页 / 共17页
第8页 / 共17页
第9页 / 共17页
第10页 / 共17页
亲,该文档总共17页,到这儿已超出免费预览范围,如果喜欢就下载吧!
资源描述
为了适应公司新战略的发展,保障停车场安保新项目的正常、顺利开展,特制定安保从业人员的业务技能及个人素质的培训计划病例报告英文CASEMedicalNumber:GeneralinformationName:DingZierAge:FortysevenSex:FemaleRace:HanOccupation:farmerNationality:ChinaMaritalstatus:MarriedAddress:jianlicounty,JingzhouCity,HubeiProvinceDateofadmission:April17,XXDateofrecord:April17,XXComplainerofhistory:thepatientherselfReliability:ReliableChiefcomplaint:Intermittentlowbackpainfor10yearsPresentillness:Tenyearsago,thepatientsuddenlyfeltpaininthelowerback,withhematuria,butnourinaryfrequency,urgency,dysuria,feverandothertheLeftkidneystonesremovalsurgery,Patientswithlowbackpainyearsago,patientsfeltintermittentlowbackpainwithurinaryfrequency,urgencyagain,nodysuria,hematuria,feverandothersymptoms,thepatientdidnttreatit.XX-02-24reviewedtheultrasoundfoundthatLeftkidneystones.Forthesakeoffurthertreatment,thencometoourhospital,outpatientrevenuetoLeftkidneystonestoourdepartment.Sincetheonset,thepatientsprivateprosecutionspiritedness,appetite,sleepsomewhatless,slightlymoreurination,defecationisnormal,nosignificantchangesinphysicalweight.PasthistoryOperativehistory:10yearsago,didkidneystonesremovalsurgery.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryShewasborninJianliCountyandalmostalwayslivedinJianlicounty.Shedidnotgotoschool.Herlivingconditionswereingeneral.Nobadpersonalhabitsandcustoms.Menstrualhistory:Thefirsttimewhenshewas16.Lasting5to6dayseverytimesanditscycleisabout33days.Obstetricalhistory:Pregnacy4times,4natureproduction,noabortion.Contraceptivehistory:Notclear.Familyhistory:Herparentsarestillalive.PhysicalexaminationT,P72/min,R18/min,BP116/76mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.Respiratorymovementwasbilaterallysymmetricwiththefrequencyof18/min.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate72/min.Cardiacrhythmwasnotregular.Nopathologicalmurmurs.Abdomenwasflatandsoft.Nobulgeordepression.Noabdominalwallvarices.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdominal.Therewasreboundtendernessonrenalregion.Liverandspleenwasuntouched.Nomasses.Shiftingdullnessisnegative.Novascularmurmurs.Noedema.Physiologicalreflexeswereexistentwithoutanypathologicalones.HeadCranium:Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Oralmucousmembranewassmooth,andofnoulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotenlarged.Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.Thorax:Symmetricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof18/min.Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate76/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Thereweretendernessandreboundtendernessonrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.
收藏 下载该资源
网站客服QQ:2055934822
金锄头文库版权所有
经营许可证:蜀ICP备13022795号 | 川公网安备 51140202000112号