出科病例(国外英文资料).doc

出科病例 Skin mucous membrane: normal color, whole body yellowing skin, skin rashes and hypodermic haemorrhage, distribution normal hair, skin temperature and elasticity is normal, no edema, did not see liver palm and spider angioma. Superficial lymph nodes: superficial lymph nodes are not enlarged. Head: head: normal size, no deformity. Eye: the eyelid is normal, the eye conjunctival is not congestive edema, the sclera is not yellow dye. The cornea is Often, double pupil and other large circle, diameter 3mm, the light reflection exists. Ear: the auricle is not deformed, the hearing is normal, the mastoid has no tenderness, the outside ear canal is not unusual cent Secrete. Nose: no deformity, no incitement of the nose, no abnormal secretion, no sinus tenderness. Oral cavity: the lips are not purple, the mucosa is normal, the mouth is centered, the gum is not red and swollen, flat The peach body is not swollen, the pharynx is uncongested, the tonsils are not large, and the tongue is centered. Neck: the neck is soft, the jugular vein is not angry, and the hepatic vein is negative. The thyroid gland is normal, not in the blood vessel murmur, the trachea is centered. Chest: no deformity of the chest, no pain in the chest, and normal breast development. Lung: visual diagnosis: the two lungs are in agreement. Palpation: normal chatter, no pleural friction. Percussion: double lung percussion. Auscultation: double lung breath sound, unhearted and dry, voice Normal, unsmelled and pleural friction. Heart: the apex of the heart is not diffuse, the front area has no lumps. Palpation: the apex beat is normal and does not touch the apex tremor. Right (cm) on the left (cm) 2.5 II 2.5 2.5, III, 4.0 3.5 V 7.5 The anterior median line is 9cm from the left clavicular linePercussion: the heart dullness is normal. Auscultation: HR78 / min, unhearted and pathological noise. Ventral: visual examination: the appearance is normal, do not see abdominal wall vein qu zhang. Palpation: the abdome