Main complaint: red and pain for 7 days at left side back
Current disease history: the patient suffered pain at left back 7 days ago suddenly, without obvious aversion to cold, no nausea, and no treatment is received. But the pain gets more severe. For further diagnosis and treatment, he came to our hospital, and is hospitalized due to “apostasies at back”.
Medical history: healthy in the past, denied hepatitis, tuberculosis, hyopertension, diabetes, heart disease etc. No details about inoculation history. debridement and suturing operation ever received for right forehead and right elbow due to trauma. A few years ago, ever found enclosed mass at left back, which is small and no pain. So no treatment is given.
Five sense organs of head: no photophobia, no tears when facing wind; no running nose; no hearing and listening difficulty, no toothache history.
Respiration system: no cough, expectoration, hemoptysis, aspiration difficulty history.
Circulating system: no palpitation, out of breath, cyanosis, edema, precordia pain history.
Blood system: no dizziness, nosebleed, tooth or gums bleed, or ecchymoses history;
Urinary system: no frequent and urgent urination demand, no dysuria, urination difficulty; no urination increase; no face hydropsy history;
Mobility system: no deformation of four limbs, no red swelling of joint. Free movement.
Digestion system: no sour regurgitation, eructation, abdominal pain, diarrhea history.
Incretion system: no aversion to hot, excessive sweat; no excessive drinking or food history.
Nerve system: no headache or dizziness history.
Personal history: born in his own country, never been to the epidemic area of schistosome; denied traveling or living history in epidemic of contagious area; no suspected or confirmed contact history of bird flu, SARS patients. Regular life, good economic conditions, no drinking, smoking or other addictions.
Allergic history: denied medicine or food allergic history.
Marital history: married; the spouse is healthy; satisfied with marriage and family life.
Family history: family members healthy; denied malignant tumour, heat disease, diabetes, hereditary disease and contagious disease history.
T 36,2℃P 72次／分R 18次／分BP110/70 mmHg
T: 36.2°C P: 72 times/min R: 18 times/min BP: 110/70 mmHg
General status: well developed, medium nutrition; clear minded, active position, normal walking, answering correctly, cooperation during examination.
皮肤粘膜： 垒身皮肤特膜无黄染，无紫钳、未发现皮疹及皮下出血点及瘀斑。全身皮肤未发现手术瘢痕。背部 有纹身。
Skin mucosa: no yellow stain on skin of full body, no cyanosis; no erythra, nor subcutaneous hemorrhage and petechia; operational scar not found on full body skin; tattoo on back.
Lymph node: no swelling of lymph ndoe.
Head: normal size and shape, no deformation of five organs, no hydropsy of eyelid, no hyperaemia of conjunctiva; no protrusion of eyeball; no yellow stain of sclera; equal size and round shape of pupils at both sides, with diameter about 3mm; sensitive to light. No secretion of external auditory meatus; no tenderness of mastoid; no flaring of nose. No fluid or blood from nasal cavity; no tenderness paranasal sinus; the lips are red without cyanosis; No blooding point at oral mucosa. Red tongue, white moss, no hyperaemia at throat, no tumescence of tonsil.
Neck: bland neck without resistance; no distention of jugular vein; abnormality of abnormal pulsation of carotid not found; no swelling of thyroid; node not touched, the trachea located at center.
胸部：胸廓对称无畸形，胸毛较多，双肺呼吸运动正常，叩诊清音，听诊呼吸音清晰，未闻及干湿性罗音。心前区无隆起，心尖搏动于左第五肋问锁骨 中线内约2cm，心浊音界正常，心率7 2次／分，心律整齐，心脏各瓣膜区未闻及病理性杂音。
Chest: chest symmetrical without deformation; a lot of sternal seta; normal aspiration of both lungs; clear sound during percussion, clear aspiration sound during acouophonia; no wet or dry rale is heard. No precordia eminence. The apex of the heart pulsates at the place about 2cm inside the central line of clavicle at left 5th rib. Normal border of cardiac dullness; HR 72 times/min with good rhythm; no pathological noise is heard at various valves of heart.
Abdomen: flat abdomen; no gastroenteric type or gastroenteric rushes; no distention of vein of abdominal wall; abdominal aspiration not limited; soft abdominal muscle; no tenderness or rebound pain at abdomen; no tenderness at liver area; normal border of liver dullness; liver and spleen not palpable. Murphy: negative. No mobile voiced sound. No tenderness or percussed pain. Normal borborygmus; no noise of blood vessels is heard.
Anus and external genital organs: not examined.
Backbone and four limbs: physiological bending of backbone, no tenderness or vertical percussed pain. Free movement of four limbs. Normal muscle force and muscle strength. No swelling of joint. Movement not restricted. No swelling of both legs. No venous hemangiectasis.
Nerve system: normal nervous ad psychological reflection of both knees etc. No pathological reflection of Babinski’s sign is induced.
A red enclosed mass is seen at the left back, with the diameter of about 5-6cm; Positive for tenderness; fluctuation at center; high local humidity; bad movement.
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