腹泻案例(国外英文资料).doc

腹泻案例 Health history Name: liu huanhuan: fuzhou, fujian province Gender: female home address: 3 high road in fuzhou, fuzhou, fujian province Age: 42-year-old working unit: no Marriage: admission time for unmarried: 8, 8, 2008 Nationality: history of han nationality: 2008 8 11:45 AM Occupation: no history gatherer: patient (reliable) Allergy history: penicillin Chief complaint: 4 days of diarrhoea Present history: 4 days ago there was no apparent cause of diarrhoea, and the daily solution of the egg was 4 ~ 5 times, with a little mucus, no pus, no obvious smell. No abdominal pain, bloating, and black. When you eat, you will vomit, not jet. Vomit is the content of the stomach contents, no vomit coffee sample. Taking the medicine at home, the diarrhea intensified a day ago, and the daily solution of the soup was 10 times a day, and the urine was reduced, the water was thirsty, and the limbs were cold. He came to our hospital. Since the onset of the disease, the mood, appetite, the sleep is good, the urine is like the aforementioned, the weight is slightly reduced. Previous history: pingsu health, no history of hypertension, diabetes, etc. There is no history of infection such as hepatitis b, tuberculosis, no surgery, no history of trauma, no food, no history of drug allergy. Menstrual history: 14 LMP 2008.7.28 4 to 5 30 Marital history: married, a child, not a close relative. The husband and the son are healthy. Personal history: born in the original country, denying the history of living in the epidemic area and the history of contact with toxic substances; No tobacco and alcohol addictions; Deny the history of the smelt. Family history: parents health, non-inbreeding, hepatitis, tuberculosis and other infectious diseases, no hereditary, immuno-metabolic history and history. Nurse diagnosis Diarrheal: linked to intestinal infection. Insufficient fluid: it is associated with loss of fluids. Block check Admission: PE T36.7 ℃, weight 6.8 kg, normal nutrition, eye socket