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Chinese PLA General Hospital

Medical Records

Outpatient No.: Y222222

Records of First Admission

Female, 28 years old, Han, family register: Haidian District, Beijing, work unit: student, unmarried. She admitted at 15:52 on July 25, 2017. The medical history was collected at the admission day and told by the patient, which is reliable.

Main complaint: the patient has been difficulty in swallowing for nearly 9 months and aggravated with food reflux for 6 months.

Present medical history: the patient was difficulty in swallowing in November 2016 without obvious cause, especially after eating solid food. No food reflux, no sour regurgitation and heartburn, no substernal pain, no nausea and vomiting, no abdominal distension and pain, no chest distress and shortness of breath. She received the treatment from Peking University People's Hospital on Dec. 26, 2016 and received gastroscopy, the results showed that: the esophageal mucosa is smooth. No brown area found under NBI. Distance between toothed portion and incisor was 40 cm. Distal esophagus showed chrysanthemum pattern. Cardiac orifice had a sign of breaking. The cardiac orifice didn’t show loose when reversing it; piebaldness can be found on mucosa of fundus of stomach. Mucus had been counted and showed yellow green; piebaldness can be found on gastric mucosa. Piebaldness can be found on incisura mucosa of gastric angle. Piebaldness can be found on mucosa of antrum of stomach; pattern of sprinkling salt can be found behind the duodenal bulb. The diagnosis was: achalasia of cardia? Chronic Superficial Gastritis, duodenitis at descending part of duodenum. The patient received pathological examination and immumohistochemical staining results showed: antrum of stomach Hp(-). The patient was suggested receiving operation for treatment, but the patient refused. The hospital gave her medicines orally taken to promote relaxation of smooth muscle tissue (details unknown). Since the patient was difficulty in swallowing, she didn’t take it regularly, so the symptom of difficulty in swallowing aggravated in the recent half year and accompanied with food reflex. Vomitus were almost mucus with food she taken, at the same time, she felt sour regurgitation and heartburn, substernal pain as well as abdominal distension. No abdominal pain. She sought for treatment from Peking University People's Hospital on the early July 2017, and the abdominal ultrasound examination showed: no abnormity in liver, gallbladder, pancreas, spleen and both kidneys. The examination of upper gastrointestinal contrast showed: Barium passed the esophagus slowly and beaking narrow can be found at lower esophagus, with widest section of 5 cm. The diagnosis was: possible achalasia of cardia, please combine with clinical examination. To further treat the illness, the patient has been transferred to our hospital, and admitted by Outpatient department by “achalasia of cardia” to our department. The patient is in good spirit at present, with normal physical strength and appetite. She is still suffering from difficulty in swallowing, but with normal sleeping. She lost weight for about 5 kg in the recent half year and has regular bowel movements for 2-3 days/time and normal micturition. She admitted to our hospital for further examination and treatment.

Past medical history: The patient denied medical history of hepatitis, tuberculosis, malaria and so on and denied medical history of high blood pressure and heart disease.

Chinese PLA General Hospital

Medical Records

Outpatient No.: 

The patient denied medical history of diabetes, cerebrovascular disease, mental disease. The patient denied operation history, rtauma history, transfusion history, allergies to medications or food. History of prophylactic inoculation is unknown.

Personal history: The patient was born in Haidian District, Beijing and lives here. No living history in epidemic area, history of epidemic situation and history of contacting with infected water. No living history in a pasturing area, mine, high fluorosis area, low iodine area. No contact history with chemical substance, radiation, poisonous substance, drugs. No smoking history and drinking history.

Marital and reproductive history: unmarried and childless.

Menstrual history:  on July 12, 2017

Family medical history: Both parents are in good health. No history of infection and genetic disease in her family.

Physical Examination

Body temperature: 36.6℃, pulse: 78 times/ min., breath: 18 times/ min., blood pressure: 128/70 mmHg, height: 155 cm, weight: 37 kg, BMI: 15.4. She develops normally and is well-nourished. She has normal face and natural expression. She is in active position, has clear mind and can cooperate with physical examination. She has normal skin and mucosa all over the body. No stained yellow, no rash, no subcutaneous hemorrhage, no subcutaneous nodules, no scar, with evenly distributed hair. No cutaneous dropsy, no liver palms, no spider nevus. No superficial lymph node enlargement and tenderness all over the body, normal head, no malformation, no palpebral edema, blepharoptosis or hypophasis. Normal conjunctiva, normal eye ball, no icteric sclera, both pupils with equal size and equal circles, with diameter of about 3 mm, normal to light reflex. The external auditory canal is unobstructed, no abnormal secreta. No tenderness in the mastoid area, no hearing disorder. Normal smell. No cyanosis of lips, no abnormity of mucous membrane of mouth. Normal coating on the tongue, no fremitus and declination when extending tongue. Normal gingiva, pharyngeal mucosa. No antiadoncus. The neck is soft, no resistance. The carotid pulsation is normal and jugular vein is normal. Trachea is in the midline and hepatojugular reflux sign shows negative. The thyroid is normal, no pressing pain, fremitus, vascular murmur. The thorax is normal, no malformation. No sensitive percussion found in sternum. Breasts on both sides are symmetry, no abnormity. The breathing movement is normal, intercostal space is normal and vocal fremitus is normal. The percussion note is clear, and the breath is regular. Breath sounds of both lungs are clear, no dry and wet rale and pleural friction sound being heard. No protrusion of precordium.

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