主诉:体重减轻、发作性四肢乏力4年,加重办四肢疼痛1月
Chief complaint: loss of weight, paroxysmal weakness of limbs for four years, aggravating for
one month accompanied by pain of limbs
现病史:2003年10月患者无明显诱因出现体重减轻,半年时间内体重下降约20 kg,自觉脾气暴躁、手抖,未予重视。
History of present illness: in October, 2003, the patient had the symptom of body weight loss without overt inducement, about 20KG in half a year. He himself felt that he became bad-tempered, hand-trembling, but he did not pay much attention.
2004年一月,患者无明显诱因出现四肢乏力,不能行走,无呼吸困难、吞咽困难,到省人医就诊,查血钾2.94mmol/l,及甲状腺功能(具体不祥),诊断为“甲亢,
甲亢低钾性周期性麻痹”,竟不加治疗后症状好转。后间断服用“丙硫、他巴唑”,未规律服药,未规律复诊。2006年12月患者四肢乏力再发,症状同前,经补钾后症状缓解。
In January, 2004, the patient had the symptom of body weight loss without overt inducement and was unable to walk without dyspnea or dysphagia. So he went to People’s hospital of Hunan Province and had blood potassium and thyroid examination (details not known),and was diagnosed hyperthyroidism, hypokalemic periodic paralysis. Though he did not take any treatment, his symptom relieved. Then he took propylthiouracil(PTU) and tapazole irregularly and he did not have follow-up observation in hospital. In December, 2006, his symptom relapsed and he took postase for treatment. Then his symptom relieved.
2007年9月15日左右患者无明显诱因出现四肢乏力,呈持续性,无晨轻暮重,无呼吸
吞咽困难,以颈,肩和髋部肌群为甚,可行走,感登楼、蹲位起立、洗脸、梳头、提裤困难,咳嗽乏力,活动时感肌肉酸痛。2007年9月18日到163医院就诊,予停用“他巴唑”,9月25日行“碘131”治疗,后症状无缓解。10月9日至省人医住院治疗,诊断不清,未予特殊处理,转入我院。起病以来患者无畏寒发热,无心悸气促,精神食欲稍差,大小便正常。
On 15th,September, 2007, his symptom appeared again ,which was durative without the characteristics of aggravation at night and alleviation in the morning or dysphagia. He felt the symptom was especially severe in the muscle group of neck, shoulder and hip. He could walk, but felt difficult in going upstairs, rising at squatting position, washing his face, combing his hair, lifting his pants and coughing. He felt muscular soreness on exertion. On 18th,September,2007, he went to 163 Hospital for treatment and was advised to cease using tapazole. On 25th ,September, he took the treatment of Sodium Iodide[131I], but the symptom persisted. On 9th, October, he went to People’s Hospital of Hunan Province. God only knows. His treatment was not special and transferred to our hospital. Since he was ill, he did not have the symptom of chills, fever, palpitation or tachypnea. His spirit and appetite were a little bad. The urination and defecation were normal.
个人史:吸烟1包每天,25年
Persona l history: he smoked for 25 years ,about one packet per day.
家族史:家族中两姐姐有甲亢病史。
Family history: his two elder sisters had the medical record of hyperthyroidism |