CASE
Medical Number: **********
General information
Name:** Age: 25 years old
Sex: Female Race: Han
Occupation: others Nationality: China
Marital status: Married Address: Wuhan,Hube
Tel楚庄: *********
Date of admission: Dec.27th, 2015 Date of record:11am, Dec.27th, 2015
Complainer of history: the patient herlf Reliability: Reliable
Chief complaint: 延迟发货The patient was found cessation of menstruation for 36+2w and vaginal bleeding for over one week.
Prent illness: The patient had regular mens previously. The first time when she was 14. Lasting4days every times and its cycle is about 30-45 days.LMP: 2015-4-17. Uric HCG test was positive after 50 days of amenorrhea. On 2015-6-10,her type-B ultrasonic revealed Intrauterine early pregnancy,correspond to gestational week of 6weeks+.According to the early ultrasonic result,we calculate EDC is 2016-2-2.The patient did not have obvious naua and vomiting of pregnancy (NVP)in early stage of pregnancy .Fetal movements were felt in 4 months’ gestation. She did ante-partum examination for totally ven times,but did not do down's screening and TORCH screening.OGTT showed that the level of her fasting blood gluco is 5.17mmol/L,while the level of postprandial blood sugar is normal.In the cour of gestation, the patient did not get in touch with any radioactive rays,toxicant or pets. On 2015-12-20,the patient went to local hospital for treatment as a result of a little vaginal bleeding. After admission,she was given magnesium sulfate for fetus protection and dexamethasone for promotion of fetal lung maturity.when her bleeding station is under co
ntrol, she left hospital. On 2015-12-26,as a result of “large amount of vaginal bleeding,more than menstrual blood volume”, she went to Central Hospital of Xianning with emergency visit. After admission, she was given Ritodrine for fetus protection. And then she was nt to our hospital for further treatment. Until today, the patient is found cessation of menstruation for 36+2w,and further accounting gestational age is 35 weeks according to the ultrasonic. There is still some dark red vaginal bleeding. While the patient did not feel abdonimal pain, and there was no vaginal discharge. So she was accepted to our hospital and her diagnosis was “36+2weeks of gestation, Dangerous placenta previa”. After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation. Her strength is a little diminished, and the weight has physiological changes.
Past history
Health status:good.
Operative history: She received cesarean operation in 2011.
Infectious history: No history of vere infectious dia.
Allergic history: She was not allergic to penicillin or sulfamide.
Respiratory system: No history of respiratory dia.
Circulatory system: No history of precordial pain.
Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary dia.
Hematopoietic system: No history of anemia and mucocutaneous bleeding.
Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
She was born in Hubei and almost always lived in Wuhan. There was no any endemic dia in Wuhan. Her living conditions were good. No bad personal habits and customs.
Menstrual history: The first time when she was 14. Lasting 4days every times and its cycle is about 30-45 days. LMP: 2015-4-17.
Obstetrical history: marital age:22 years old.Pregnacy 4 times, once cesarean delivery.induced abortion 2 times.
Family history: Her parents are both alive.
Physical examination
T: 36.0℃ P: 76/min R: 20/min BP: 112/67mmHg
General appearance: Patient is a 25 years old female who appears pleasant, in no appe
rant distress, given her age, well developed and well nourished. Oriented to person, place and time.
Lymph nodes: Not enlarged.
组织委员述职报告Skin: No jaundice or rashes. No cyanosis and bruis. No edema.
施工计划表Head: Skull and scalp normal. No tenderness. No loss of hair.
Eyes: No edema in eyelids, no ptosis, no conjunctival congestion.Width of palpebral fissures is normal. No jaundice. Pupil’s size and shape is normal. Corneal is clear. No exophthalmos.
Ears: Auditory acuity is excellent. No ear purulent discharge.
No: Shape is normal. No obstruction. No deviation of nasal ptum.
Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tonsils not enlarged.
Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.
Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass.
Lung:
Inspection: Respiration regular. Degree of expansion is symmetry.
Plapation: Tactile fremitus symmetrical.
Percussion: extensive resonance to percussion.
Ausculation: Clear to ausculation with no rubs noted.
Heart:
Inspection: No abnormal pulsation or retraction.
Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the left mid-clavicular line.
Percussion: The border of cardiac is not enlarged.
Ausculation: The heart sounds were of good quality and the rhythm was regular.
Heart rate: 76/min. No bruits.
南瓜酥Right(cm) Rib interspace Left(cm) |
2.5 Ⅱ 2冬季滋补汤大全 |
2.5 Ⅲ 4 |
汽车厂实习报告 3 Ⅳ 6 |
Ⅴ 8 |
|
The left mid-clavicular line is 8.5 cm away from front midsternal line.
Radial pul is normal.
Abdomen:
Inspection: Universial abdominal bulge. Dilated veins unobrved.
Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy’s sign is negative. For details e obstetric examination.
Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space.
