Name: Aiyu SunAge: 37Gender: FemaleRace: the Han nationalityBirth Place: HongHu CityMarital Status: MarriedOccupation: FarmerAddress: Group Six, WeiGou Village, FengKou Town, HongHu City, Hubei Province Informant: Aiyu SunDate of admission: June 3 , 2010Date of history taken: June 3 , 2010Chief Complaint:Feeling hot, palpitation, polyphagia for four months, fever for five daysHistory 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: FT3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/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 and urine were as usual. Physical strength descended. Weight was stable.Past History:General Health Status: good √moderate poorInfectious Disease: √no yes(if any, please write down date of onset, brief diagnostic and therapeutic, course )Typhoid fever Dysentery Malaria Schistosomiasis Leptospirosis Tuberculosis Epidemic hemorrhagic fever othersAllergic history: √no yes (clinical manifestation: allergen: ) Trauma and/or operation history: √no yesReview of Symptoms:Respiratory system: √no yesRepeated pharyngeal pain:chronic cough: expectoration: Hemoptysis: asthma: dyspnea: chest pain:Circulatory system:√no yesPalpitation: exertional dyspnea: cyanosis: hemoptysis: Edema of lower extremities: chest pain: syncope: hypertension:Digestive system:√no yesAnorexia: dysphagia: sour regurgitation: eructation: nausea: Emesis: melena: abdominal pain: diarrhea: hematemesis: Hematochezia: jaundice:Urinary system:√no yesLumbar pain: urinary frequency: urinary urgency: dysuria: oliguria: Polyuria: retention of urine: incontinence of urine: hematuria: Pyuria: nocturia: puffy face:Hematopoietic system:√no yesFatigue: dizziness: gingival hemorrhage: epistaxis: subcutaneous hemorrhage:Metabolic and endocrine system:√no yesBulimia: anorexia: hot intolerance: hyperhidrosis: cold intolerance: Polydipsia: amenorrhea: tremor of hands: character change: Marked obesity: marked emaciation: hirsutism: alopecia: Hyperpigmentation: sexual function change: impotence: amenorrhea:Musculoskeletal system:√no yesMigrating arthralgia: arthralgia: artrcocele: arthremia: Dysarthrosis: myalgia: muscular atrophy:Neurological system:√no yesDizziness: headache: paresthesia: hypomnesis: Visual disturbance: Insomnia: somnolence: syncope: convulsion:Disturbance of consciousness: paralysis: vertigo:Personal history:Resident history in endemic disease area:√no yesSmoking: √no yes: about___yearsDrinking:√no occasional frequent: about____years average____ml/day Others:In April 2009, the patient was diagnosed as “polyp of vocal cord” in our hospital and got medicine thrapy.Menstrual history:Menarchal age: 21 years old duration__5__days/ interval_30_daysLast menstrual period: 2010.5.1 menopausal age: _13_years oldAmount of flow: small √moderate largedysmenorrheal: presence √absenceMarital and obstetrical history:Married age: 21 years old pregnancy_4__times natural labour: 3 timesAbortion: 2 times premature labour: 0 times still birth: 0 timesDystocia and its course:0Family history:(pay attention to the infectious and hereditary disease related to the present illness)Father: √healthy ill: deceased cause:Mother: √healthy ill: deceased cause:Others: noPhysical ExaminationGeneral conditions:Temperature: 37.3°C pulse:88 times per minute (√regular irregular)Blood pressure:139/84mmHg respiration: 20 times per minute (√regular irregular) Development: √normal HypoplasiaNutrition: good √moderate poor cachexiaFacial expression: √normal acute chronic other( )Posture: √active semi-reclining position other ( )Mental status:√clear confusion somnolence delirium comaGait: √normal abnormal cooperation: √yes noSkin and mucosa:Color:√normal pale cyanosis stained yellow pigmentationrash:√no yes: (type: distribution: )subcutaneous hemorrhage: √no yes (type: distribution: )Hair distribution: √normal hypertrichosis oligotrichosis alopecial(location: ) Temperature and moisture: √normal cold warm dry moist dehydrationEdema: √no yes ( location and degree )Liver palmar : √no yes spider angioma:√no yes (location: )Others: noLymph nodes:enlargement of superfacial lymph node: √no yes (location and description: ) Head: without abnormityCranium: without abnormityEye: exophthalmos: exophthalmos of both eye ballseyelid: without descensusconjunctiva: without edemasclera: without stained yellowCornea: √normal abnormal ( od os )Pupil:√equally round and equal in size: unequal (od os )Pupil reflex: √normal delayed (od os ) absent (od os ) others:Ear: discharge of external auditory canal:√normal (left right quality: ) Mastoid tenderness : no (left right )disturbance of rough hearing test: yes √noNose: flaring of alae nasi:√no yesstuffy discharge:√no yestenderness over paranasal sinuses: √no yes(location: )Mouth: lip: redMucosa: without ulcerationTongue: stretched tongue is in the middleGum: nomalTonsil: Ⅰ°enlargement of both sidesPharynx: congestionsound: √normal hoarseness teeth: √normal absent carieNeck:neck rigidity √no yes (distance between sternum and mandible: ______transvers fingers) Carotid artery: √normal pulsation increased pulsation marked distention Trachea:√middle deviation (leftward rightward )Hepatojugular vein reflux: negativeThyroid: normal √enlarged bruitChest:Chest wall: √normal barrel chest prominence or retraction: (left right ) Precordial prominence: √no yespercussion pain over sternum:√no yesBreast: normalLung:Inspection: normal respiratory movementPalpation:vocal tactile fremitus: normalpleural rubbing sensation: √no yesSubcutaneous crepitus sensation:√no yesPercussion: √resonanc dullness Flatness Hyperresonance tympanylower border of lung: (detailed percussion in respiratory disease)midclavicular line : right:_6__cm left:_6__cmmidaxillary line: right:_8__cm left:_8__cmscapular line: right:_10__cm left:_10__cmAuscultation: breathing sound :√normal abnormalRales: √no yes (moist dry ) location:Heart:Inspection:apical pulsation:√normal unseen increase diffuse sSubxiphoid pulsation: √no yesLocation of apex beat:√normal shift (distance away from left MCL___cm) Palpation:apical pulsation: √normal lifting apex impulse negative pulsationThrill:√no yes (location: ) phase:Percussion:relative dullness border:√Normal decreased absent increaseR(cm) line L(cm)2 Ⅱ 22 Ⅲ 43 Ⅳ 6Ⅴ8Distance between anterior median line and MCL 8.5cm Auscultation: heart rate: 88bpm rhythm: regularheart sound:√normal abnormalextra sound:√no S3 gallop S4 opening snap:murmur: √no yes:location timing quality intensity transmission:effects of position:effects of respiration:P2 = A2 pericardial friction sound:√no yesPeripheral vascular sign: √no yes: paradoxical pulse pulsus alternansWater hammer pulse capillary pulsationpulse deficit Pistol shot sound Duroziez sign Abdomen:Inspection: shape: √normal distention scaphoid frog-bellygastric pattern:√no yes visible intestinal peristalsis:√no yesabdominal vein varicose: √no yes (direction: )operation scar:√no yesPalpation: √soft guarding (location: )Tenderness: √no yes (location: )rebound tenderness:√no yes (location: )fluctuation succussion splash:√no yesliver: can’t be touch ed under the ribsgallbladder: can’t be touched under the ribsMurphy sign: negativespleen: can’t be touched under the ribskidneys: kidney zones without Percussion painabdominal mass :can’t be touchedPercussion: liver dullness border: √normal decreased absentUpper hepatic border locates at right midclavicular line5_intercostal spaceShift dullness: negativePain on percussion in costovertebral area:√no yes R L Auscultation: bowel sounds : √normal hyperperistalsis hypoperistalsis absence Vascular bruit :√no yes (location )Genital organ: √unexamined normal abnormalAnus and rectum:√unexamined normal abnormalSpine and extremities:Spine: √normal deformity (kyphosis lordosis scoliosis )Tenderness (location )Extremities: √normal arthremia(location ) arthrocele (location ) Ankylosis (location ) aropachy Muscular tenderness(location ) muscular atrophy (location )Neurological system:Abdominal reflex++ cremasteric reflex- knee reflex++Kernig`s sign(R- L- ) Brudzinski`s sign:(R- L- ) Babinski sign (R- L- )Opphenheim sign(R- L- )Gordon sign (R- L- ) Lasegue sign (R- L- ) Others: noImportant exam results from out-patient service: X-ray number:no27th, April, local hospital: F T3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC 6.11*109/L, N 7.01*109/L;ALT 52u/L↑, AST 41u/L.12nd, May, local hospital: Blood-rt: WBC 5.8*109/L, N 3.1*109/L3rd, June, our hospital: Blood-rt: WBC 0.15*109/L↓, N0*109/L↓↓↓Summary of case history:1 Patient Aiyu Sun, female, 37 years old.2 Chief Complaint: Feeling hot, palpitation, polyphagia for four months, fever for five days3 Past History: General health status was moderate. In April 2009, the patient was diagnosed as “polyp of vocal cord” in our hospital and got medicine thrapy. The patient deny history of TB, HBV, schistosome infection, DM, HBP, heart diseases and other special diseases. The patient deny history of allergy, trama, surgery operation and blood transfusion.4 Physical Examination: T37.3°C P88 times per minute BP:139/84mmHg R: 20 times per minute. Normal development, moderate nutrition, active posture, clear mental status, cooperated examination. There is no yellow stained in the skin and mucosa. There is no enlargement of superfacial lymph nodes. Head shape and cranium are normal. There is exophthalmos of both eye balls. Both tonsils are Ⅰ°enlarged. Pharynx is congestion. No neck rigidity. Trachea is in the middle. Thyroid of both sides is Ⅱ°enlarged, without vascular bruit. Breathing sound of the lung is normal. And there is no rale. Heart rhythm is regular, without any obvious murmur at each valve zone. Abdomen shape is normal. Abdomen is soft, without tenderness or rebound tenderness. Liver and spleen can’t be touched under the ribs. Kidney zones are without percussion pain. Both hands are shivering. There is no edema of both lower limbs.5 exam results:27th, April, local hospital: F T3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC 6.11*109/L,N 7.01*109/L; ALT 52u/L↑, AST 41u/L.12nd, May, local hospital: Blood-rt: WBC 5.8*109/L, N 3.1*109/L;3rd, June, our hospital: Blood-rt: WBC 0.15*109/L↓, N0*109/L↓↓↓Primary diagnosis:1 Hyperthyroidism2 Agranulemia:（1）Induced by drugs；（2）Hematopoietic system diseases？(such as aplastic anemia, MDS，leukemia etc.)3 Acute upper respiratory infection4 Other diseases which cause fever: such as other infections, connective tissue diseases etc.Corrected diagnosis (date 2010.6.4)1 Hyperthyroidism2 Agranulemia: Induced by drugs3 Acute upper respiratory infectionsignature:writer: Yanling LiangRevisor:。