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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 | 甘秋凤 |
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birthday | 1967-06-21 |
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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 | 44022119670621162X |
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place of residence | 广东省韶关市曲江区 |
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marital status | married
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Highest Education Level | undergraduate college
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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 | 曲江区人民医院 |
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register number |
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date of hospital visiting | 2023-02-05 |
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department | 内科 |
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current diagnose | 甲状腺炎 |
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Consistent with the final diagnosis | yes
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content | inpatient
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hospital name | 粤北人民医院 |
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register number | 00622938 |
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date of hospital visiting | 2023-03-05 |
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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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就诊日期/住院日期 |
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department |
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current diagnose |
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Consistent with the final diagnosis |
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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 | winter
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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 | 清热散结片 |
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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 |
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time of duration（days） |
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drug name | 消炎痛 |
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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 |
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time of duration（days） |
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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 | 2023-03-05 |
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overall appearance | normal
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EENT | normal
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head | normal
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lung | normal
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abdoman | normal
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Spinal&limbs | normal
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height（cm） | 158 |
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weight(kg) | 48 |
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BMI(KG/M2) | 19.23 |
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waistline（cm） |
|
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body temperature（°C） | 36.3 |
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pulse(bpm) | 80 |
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heart rate(bpm) | 80 |
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breathe(bpm) | 20 |
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diastolic pressure（mmHg） | 90 |
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systolic pressure（mmHg） | 152 |
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degree | severe
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location | both side
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time of duration（days） | 30 |
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Whether it is the first symptom | yes
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time of duration（days） | 2 |
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Whether it is the first symptom | no
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degree | hyperpyrexia
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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 |
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yes/no | yes
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location | head
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time of duration（days） | 30 |
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Whether it is the first symptom | no
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yes/no | yes
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time of duration（days） | 30 |
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Whether it is the first symptom | no
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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 |
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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 |
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yes/no | medium
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location | both side
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time of duration（days） | 30 |
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Whether it is the first symptom | no
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yes/no | severe
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location | both side
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time of duration（days） | 30 |
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Whether it is the first symptom | no
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yes/no | |
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allergen |
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Type of Family Medical History | |
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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 | 8.35 ×109 /L |
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NEUT% | 73.4 % |
|
LY% | % |
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MONO％ | ％ |
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RBC | ×10^12 /L |
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HGB | g/L |
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PLT | ×10^9 /L |
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Researcher signature | 熊周怡 |
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Date | 2023-03-06 yyyy-mm-dd |
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ESR（mm/h） | 81 |
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C-reaction protein（Mg/ml） | 10.73 |
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Thyroid stimulating hormone, TSH | <0.005 uIU/ml |
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FT3 | 5.89 pmol/L |
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FT4 | 26.62 pmol/L |
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Anti-TG | 191.22 IU/ml |
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Anti-TP0 | 3.03 IU/ml |
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Diagnosed as | Hyperthyroidism
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TRAb（IU/L） | 0.36 |
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Thyroid morphology | unclear
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Taken technetium function | decrease
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description | 甲状腺显影不清，摄锝功能减低 |
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thyroid enlargement | right
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left lobe width（mm） | 17 |
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left lobe thickness | 19 |
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right lobe width(mm) | 34 |
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right lobe thickness(mm) | 26 |
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isthmus thickness(mm) |
|
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echo | echo thickening
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Blood flow situation | normal
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decribe | 甲状腺双叶非对称性重大，并多发结节，ACR-TI-RADS分类：3类，甲状腺回声增粗 |
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Based site | |
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pathology results | |
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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
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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 |