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第1次查房(5月18日) 进修医师甲:报告病历摘要患者,男,16岁。自记事起有轻度甲状腺肿大,近二年来疲乏无力,记忆力减退,食欲略下降,常有便秘,甲状腺也较前明显增大变硬。一月前外院查吸碘率明显增高,门诊以甲亢?于1985年5月15日收住院。既往体健,父母非近亲婚配,父母及一妹正常,非缺碘及高碘区居民。体查:T:36℃,R18次/分,P64次/分BP:92/54mmHg,发育正常,营养中等,身高160cm,智力正常,全身无浮肿,无突眼,听力无障碍、颈软、甲腺Ⅲ°弥漫性不对称肿大,质Ⅱ°无压痛,右上叶有一枣红大结节,随吞咽活动,未闻血管杂音。心肺腹四肢无异常,外生殖器发育良好。
First round of rounds (May 18) Training physician A: Summary report of patient history, male, 16 years old. Since the memoir mild mild goiter, fatigue in the past two years, loss of memory, a slight loss of appetite, often constipation, thyroid also significantly increased harden compared with the previous. A month ago, the outer hospital iodine detection rate was significantly higher, out-patient hyperthyroidism? May 15, 1985 admitted to hospital. Past physical health, parents and non-relatives marriage, parents and a sister normal, non-iodine and iodine residents. Physical examination: T: 36 ℃, R18 beats / min, P64 beats / min BP: 92 / 54mmHg, normal development, medium nutrition, height 160cm, normal intelligence, no edema, no exophthalmos, Athyroid gland Ⅲ ° diffuse asymmetric swelling, quality Ⅱ ° no tenderness, right upper lobe has a big red tuberosity, with swallowing activity, no smell of vascular murmur. Cardiopulmonary abdominal limbs no abnormalities, external genitalia well developed.