Patient information 7/30

Age  : 50 years old

Sex  : female

Occupation : house wife

Date of admission : 14/7/2015 at 12pm

Chief complaints : swelling in whole body since four month

History of presenting illness: as per my patient she was apparently alright 12 month back but then she developed pain in the epigastric region which was gradual in onset

And mild it was non radiating pain with no aggravating and relieving factors

8 month later patient notice generalized swelling in the whole body which was insidious in onset and progressive in nature there was no diurnal variation no aggravating factor but relieved by medication it was associated with distension of abdomen since 3 month

No history of fever, vomiting, and nausea, appetite loss and weight loss

Past history : there is no history of similar complaint in the past, there is no relevant surgical history except of tubectomy, no history of any trauma, no history of any specific illness like diabetes mellitus tuberculosis hypertension jaundice and bronchial asthma .

There is no history any drug allergy

Personal history : the patient is illiterate, eats mixed diet, no history of any addiction, bowel habits normal but there is urgency and hesitancy during micturition

Family history: no history of similar complaint in other family members.

 

年齡 ：50歲

性別 ：女

職業 ：家庭主婦

住院日期：14/7/2015 早上12點

主因 ：4個月前開始全身浮腫

症狀發展：我的病人在12個月前都是正常的，後來在上腹區出現疼痛，但其疼痛是溫和的而不是刺激的且沒有加重及其他原因，8個月後病人開始注意到全身開始沒有徵兆的慢慢產生浮腫，而這浮腫並沒有規律的變化且程度不嚴重且可靠吃藥緩解。這症狀與三個月前開始的腹脹有關。

過程中沒有發燒、嘔吐、噁心、食慾不振及體重減輕。

過去紀錄：過去無相關得病、手術(tubectomy除外)、外傷及特定疾病(如：糖尿病、結核病、高血壓、黃疸及隻管哮喘)的記錄

沒有藥物過敏記錄

個人紀錄：患者為文盲，吃混和的食物，無成癮記錄，排便正常但會尿急，且排尿緩慢。

家族病例：家庭成員中並無相關疾病記錄。