【很好的内科病历分析例题】（[a good case history of medical records]）.docVIP

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【很好的内科病历分析例题】（[a good case history of medical records]）.doc

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【很好的内科病历分析例题】（[a good case history of medical records]）

【很好的内科病历分析例题】（[a good case history of medical records]） ; [a good case history of medical records] IPT F (confirm (+) + screen + send a message? ) = = true) MsgrObj.InstantMessage (person);} Medical postgraduate network | | community medical entrance examination Free medical examination questions | network Medical site self-help link | Back home [a good case history of medical records] Ljw323 1, Lou Zhu Number: 001 case summary: the patient female, 25 years old, because of pale, dizziness, fatigue, more than 1 years, aggravating accompanied by palpitation, 1 months to examine. 1 years ago, no obvious cause of dizziness and weakness, the family found less rosy complexion, but can work as usual, nearly 1 months to increase with palpitation, went to the hospital to check that the low hemoglobin (specific and unspecified), for oral ferrous sulfate, because the stomach is difficult By using only 1 days after eating normally, not picky, two is normal, no bleeding, melena, abnormal color of urine, epistaxis and gingival bleeding. Sleep well, no significant change in weight. Past physical health, no history of stomach disease, no history of drug allergy. Six months of marriage, menarche 14 years old, 7 days /27 days, the last menstrual cycle, half a month ago, nearly 2 years menstrual volume, more obvious for six months. Physical examination: T 36 C, 104 P / min, R18 / min, Bp 120/70mmHg, general condition is good, anemia appearance, skin mucous membrane without bleeding point, superficial lymph node is not big, sclera is not yellow, lips pale, tongue papillae normal, heart and lung no abnormalities, liver and spleen is not big. Test: Hb 60g/L, RBC 3, 1012/L, MCV, 70fl, MCH, 25pg, MCHC 30%, WBC 6.5, 109/L, classified: neuter, 70%, 27%, 3%, PLT 260? 109/L, reticulocyte 1.5%, urinary protein (-), microscopy (-), fecal occult blood, serum iron (-) 50 g/dl?. Time: ready for 5 minutes, oral answer 10 minutes, scoring points: (total score of 20 points) Diagnosis and diagnosis (8