Professional Documents
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General information
Sex: Female
Race: Han
Occupation: Teacher
Nationality: China
Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500
Reliability: Reliable
Chief complaint: Right breast mass found for more than half a month.
Present illness: Half a month ago, the patient suddenly felt pain in her right chest when
she put up her hand. After touching it, she found a mass in her right breast, but no
tendness, and the patient didn’t pay attention it. Then the pain became more and more
serious, so the patient went to tumour hospital and received a pathology centesis. Her
diagnosis was breast cancer. Then she came to our hospital and asked for an operation.
Since onset, her appetite was good, and both her spiritedness and physical energy are
Past history
Personal history
She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from
senior high school. Her living conditions were good. No bad personal habits and customs.
Menstrual history: The first time when she was 14. Lasting 3 to 4 days every times and its
Physical examination
T 36.4℃, P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished.
Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin
eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not
enlarged.
Head
Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No
tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in
external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.
Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not
congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was
normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary
Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in
Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in
midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space
Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was
fine.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min.
Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction
fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No
wheezes. No rales.
Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of
maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not
diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were
strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs.
Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound
tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No
murmurs.
Neural system: Physiological reflexes were existent without any pathological ones.
Investigation
No.
Professional Examination
There are a about 3*3*2 cm mass in outer-up field of her right breast. It is hard but no
tendness. It can be moved and its surface is smooth. The skin of her breast is normal.
Corresponding superficial lymph nodes don’t enlarge.
History summary
4. Physical examination showed no abnormity in lung, heart and abdoman. Information about
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