(临床诊断学) 仁济临床医学院诊断学教研室 An Introduction to Clinical Diagnostics

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Example Medical history


Name: Guo Yi Occupation: student

Sex: male Address: No 852,Beijin Road, Shanghai

Age: 20 years old Time admission: 5PM Feb 14 2003

Nationality: Han Time recording: 5PM Feb 14 2003

Birthplace : Shanghai Reliability: Reliable

Marital status: Unmarried History offer :Himself

Chief complaint :

Epigastric pain and melena for two days



Present illness :

The patient presents with an 8-year history of duodenal ulcer. Two days ago he felt abdominal pain, the pain was located in the epigastric area and was burning in quality. The pain occurred on an empty stomach 2 to 4 hours after meals and/or at night, was relieved by antacids and accompanied with the symptoms of epigastric fullness, belching, bloating and early satiety. After the pain he emptied the bowels characterized by dark black, liquid, tarry, metallic-smelling stool, it was about 5oo ml, 2-3 times per day. The patient also reported vomiting 50 ml “coffee grounds” material once. After then he felt palpitation, cold sweating and dizzy, and syncoped for 10 minutes. So he was presented to emergency room. Occult blood test +, skull CT scan (-) , emergency endoscopy showed duodenal ulcer (A1stage), blood routine: WBC 11*109, GN 75% ,Hgb 9.5g/l ,hematocrit value 29%.He was then admitted to the hospital for evaluation and treatment.

He denied having taken Non-steroidal Anti-inflammatory drugs before hemorrhage.

Past history :

prior major illnesses and injuries : The patient has a 3-year history of Hypertension. he denied the history of Diabetes Mellitus.

prior operations :No prior operations

prior hospitalizations : No prior hospitalizations

allergies : No food, medications, chemicals allergy.

age appropriate immunization status : Unknown


Social history :

marital status : Unmarried

current employment : student

use of drugs : No medications were daily used

use of alcohol : No drinking

use of tobacco : No smoking

level of education : Middle school

sexual history : Denied perverted sexual history


Family history :

Health status or cause of death of parents, siblings, and children : All are healthy

Specific diseases related to problems identified in the chief complaint or history of the present illness and/or system review : None

Diseases of family members which may be hereditary or place the patient at risk : No hereditary diseases



Review of systems :

Respiratory system : Denied dyspnea, hemoptysis, asthma, bronchitis, orthopnea, emphysema.

Cardiacvascular system : Denied dyspnea ,paroxysmal nocturnal dyspnea, orthopnea, edema ,but chest pain, palpitations

Gastrointestinal system : Denied rectal bleeding, vomiting blood, black tarry stools, abdominal pain,jaundice, hepatitis, diarrhea, change in bowel habits, constipation.

Urinary system : Denied polyuria, dysuria, hematuria, incontinence, urinary infections, stones.

Hematologic system : Denied anemia, easy bruising or bleeding.

Endocrine system : Denied thyroid trouble, heat or cold intolerance,excessive sweating,diabetes;excessive thirst,hunger or urination.

Musculoskeletal system : Denied joint pains or stifness,srthritis, gout, backpain. Denied muscle pains and cramps.

Neurological system : Denied seizures,paralysis,local weakness, numbness, tremors, memory problems

Physical examination

Vital signs :

T:36.3℃; P:72/min ; R:18/min ; BP:140/80mmHg



General appearance:

Well developed and nourished male, pleasant and cooperative.



Skin and Mucosa:

No edema, jaundice. No rashes , ecchymoses present, no ticks noted. Slight anemia countenance.



Lymph Node:

No pathological enlargement of superfical lymph nodes.



Head:

Eyes: Conjunctiva is pale, no other obvious abnormity

Ears: No obvious abnormity

Nose: No obvious abnormity



Neck:

soft, no venous engorgement. thyroid glands not palpable, and no thrill or brunt. trachea in midline.



Respiratory:

symmetrical chest and respiratory movements. no abnormal dullness , rales or rhonchi heard.



Cardiovascular :

maximal impulse (PMI) not visible but palpable in the 5thcostal interspace, 8cm form the middle line, no thrill. the cardiac dullness as follows:



Right (cm)

Interspaces

Left (cm)

2.0



2.0

2.0


4.0


3.0



6.0






8.0

midsternal line to midclavicular line 8.5cm

heart rate 72/min, regular. No obvious heart murmur, no pericardium friction sound.



Peripheral vascular:Pulses intact in all extremities. No irregular pulse.

Abdomen: Soft, Liver, spleen not palpable, no shifting dullness, tenderness in epigastric arer without rebound tenderness, Bowel sounds active 10-12/min,

Genitoreproductive:Normal.

Extremities: No cyanosis, clubbing, or edema.

Neurological/mental: Kerning sign negative, Brudzinski sign negative.

Motor: No obvious abnormity

Sensory: No obvious abnormity

Reflex: Biceps reflex normal, triceps reflex normal, knee jerk normal, Babinski’s sign not present .

Laboratory data

Occult blood test +

skull CT scan (-)

emergency endoscopy showed duodenal ulcer (A1stage)

blood routine: WBC 11*109, GN 75% ,Hgb 9.5g/l ,hematocrit value 29%
.Diagnosis

Duodenal ulcer accompanied by hemarrhage



Differential diagnosis
  1. Acute erosive gastritis :The patient has not a history of stress and denies taking the Non-steroidal Anti-inflammatory drugs before hemorrhage, emergency endoscopy does not find the erosive lesions. So we can exclude it.


  2. Rupture of oesophago- gastric varices: The patient has not a history of liver disease, no sign, symptom and lab experiment indicate liver cirrhosis. All evidence do not support the diease.

  3. Gastric tumor: It always occurs in elder people, makes the patients in bad condition. Occult blood test persistent positive, antacids usually can not relieve the symptom. Endoscopy and GI may help the diagnosis.



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