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inclusion criteria | Patients with anterior neck pain as the chief complaint
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Patients with one of the following exclusion criteria |
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doctor name | 熊周怡 |
- General information
- Medical information
- Relevant medication status before treatment
- Physical examination
- allergic history
- Relevant Family History
- Personal medical history and past history
- laboratory examination
- 影像学检查
- FNAC
- diagnostic scale
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patient name | 胡桂娇 |
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birthday | 1965-08-06 |
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gender | female
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nation | Han
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ABO blood type | unidentified
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RH blood type | unidentified
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certificate type | identity card
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ID number | 440221196508063523 |
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place of residence | 广东省韶关市武江区 |
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marital status | married
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Highest Education Level | junior high school
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occupation | worker
/farmer
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medical insurance | Basic medical insurance for urban workers
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name of contact |
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phone |
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content | outpatient
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hospital name | 外院 |
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register number |
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date of hospital visiting | 2022-08-10 |
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department | 内科 |
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current diagnose | 颈痛 |
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Consistent with the final diagnosis | no
|
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content | emergency
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hospital name | 粤北人民医院 |
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register number | 01123519 |
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date of hospital visiting | 2022-10-08 |
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department | 急诊 |
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current diagnose | 发热 |
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Consistent with the final diagnosis | no
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content | inpatient
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hospital name | 粤北人民医院 |
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register number | 01123519 |
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就诊日期/住院日期 | 2022-10-12 |
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department | 内分泌科 |
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current diagnose | 亚急性甲状腺炎 |
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Consistent with the final diagnosis | yes
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content | |
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hospital name |
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register number |
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date of hospital visiting |
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department |
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current diagnose |
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Consistent with the final diagnosis |
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Whether the first visiting | no
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onset season | summer
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recurrent | no
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Time of first attack |
|
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whether the drug | 是 |
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drug name | 消炎药 |
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doseage | 不详 |
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unit of doseage | |
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administration route | po
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Dosing frequency | |
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start date | 不详 |
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time of duration（days） | 3天 |
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drug name | 退热药 |
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doseage | 不详 |
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unit of doseage | |
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administration route | po
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Dosing frequency | |
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start date | 不详 |
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time of duration（days） | 3 |
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drug name |
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doseage |
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unit of doseage | |
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administration route | |
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Dosing frequency | |
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start date |
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time of duration（days） |
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Vital signs and laboratory examination | Yes
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date | 2022-10-12 |
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overall appearance | normal
|
|
EENT | normal
|
|
head | normal
|
|
lung | normal
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abdoman | normal
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Spinal&limbs | normal
|
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height（cm） | 162 |
|
weight(kg) | 53.5 |
|
BMI(KG/M2) | 20.39 |
|
waistline（cm） |
|
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body temperature（°C） | 36.5 |
|
pulse(bpm) | 94 |
|
heart rate(bpm) | 94 |
|
breathe(bpm) | 20 |
|
diastolic pressure（mmHg） | 80 |
|
systolic pressure（mmHg） | 116 |
|
degree | medium
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location | both side
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time of duration（days） | 60 |
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Whether it is the first symptom | yes
|
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time of duration（days） | 20 |
|
Whether it is the first symptom | no
|
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degree | Moderate fever
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yes/no | no
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time of duration（days） |
|
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Whether it is the first symptom |
|
yes/no | yes
|
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location | head
|
|
time of duration（days） | 20 |
|
Whether it is the first symptom | no
|
|
yes/no | no
|
|
time of duration（days） |
|
|
Whether it is the first symptom |
|
yes/no | no
|
|
time of duration（days） |
|
|
Whether it is the first symptom |
|
yes/no | yes
|
|
time of duration（days） | 60 |
|
Whether it is the first symptom | no
|
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yes/no | medium
|
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location | both side
|
|
time of duration（days） | 60 |
|
Whether it is the first symptom | no
|
|
yes/no | medium
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location | both side
|
|
time of duration（days） | 60 |
|
Whether it is the first symptom | yes
|
|
yes/no | |
|
allergen |
|
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Type of Family Medical History | |
|
kinship |
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if has hypertension | |
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if has diabetes | |
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if has coronary heart disease |
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WBC | 8.88 ×109 /L |
|
NEUT% | 80.2 % |
|
LY% | % |
|
MONO％ | ％ |
|
RBC | ×10^12 /L |
|
HGB | g/L |
|
PLT | ×10^9 /L |
|
Researcher signature | 熊周怡 |
|
Date | 2022-10 yyyy-mm-dd |
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ESR（mm/h） | 97 |
|
C-reaction protein（Mg/ml） | 11.78 |
|
Thyroid stimulating hormone, TSH | <0.005 uIU/ml |
|
FT3 | 6.58 pmol/L |
|
FT4 | 26.91 pmol/L |
|
Anti-TG | 273 IU/ml |
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Anti-TP0 | 16.5 IU/ml |
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Diagnosed as | Hyperthyroidism
|
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TRAb（IU/L） | <0.25 |
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Thyroid morphology | irregular
|
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Taken technetium function | normal
|
|
description | 甲状腺肿大，边界不清晰，摄锝功能正常 |
|
thyroid enlargement | isthmus
|
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left lobe width（mm） | 22 |
|
left lobe thickness | 26 |
|
right lobe width(mm) | 30 |
|
right lobe thickness(mm) | 27 |
|
isthmus thickness(mm) | 4.7 |
|
echo | Echo weakened
|
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Blood flow situation | normal
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|
decribe | 甲状腺内片状回声减低区，考虑甲状腺炎 |
|
Based site | |
|
pathology results | |
|
description |
|
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Thyroid tenderness（6 scores） | yes
|
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Firm on palpation（3 scores） | yes
|
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Increased ESR（3 scores） | yes
|
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elevated thyroid hormone level（2 scores） | yes
|
|
total score | 14 |
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Whether got the informed consent? | |
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Date of sign the informed consent | xx年xx月xx日 |