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Medical Records

of John Doe, Male, Born on Apr.1st,1868
(in Japanese, 奈梨 権兵衛、男、明治元年4月1日生)
Evaluated on Apr. 2nd-4th, 1998
by Dr.Yoshiro Matsuda, M.D., Director of Health Evaluation Center,
Kanazawa Medical University Hospital, Ishikawa, 9200293, Japan
E-Mail: yoshiro@kanazawa-med.ac.jp
INDEX
Clinical Diagnosis
(診断)

Summary
(サマリー)

General Status
(全身状態)
Chest & Respiratory System
(胸部、呼吸器)
Cardiological Examination
(循環器)
Gastroenterological Examination
(消化器)
Hepatobiliary Tract
(肝胆道膵等)
Neurological Examination
(神経系)
Eye Examination
(眼科)
Otolaryngological Examination
(耳鼻咽喉科))
Urological Examination
(泌尿器科)
Blood Chemistry (血液生化学的検査)
Hematology
(血球)
Liver Function Test & other
(肝機能、膵機能、蛋白分画)
Electrolyte & Renal Function
(電解質、腎機能)
Urinalysis
(尿検査)
Lipid
(脂質)
Glucose metabolism
(糖代謝)
Serologic and immunologic examination
(感染、免疫)



Clinical Diagnosis (診断)

Angina Pectoris
(狭心症)
Hyperuricemia
(高尿酸血症)
Diabetes Mellitus
(糖尿病)
Hyperlipidemia
(高脂血症)

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Summary (サマリー)
The client suffers from angina pectoris, diabetes mellitus, hyperuricemia and hyperlipidemia.

Angina: 3 tablets daily of Herbesser (diltiazem hydrochloride), have been prescribed. The angina was diagnosed in June 1997 after the client complained of oppression in the chest when climbing stairs. Though there was no abnormality in an exercise electrocardiography or in an ultrasonic cardiography, cardiac scintigraphy revealed impeded perfusion.

Diabetes mellitus, hyperuricemia and hyperlipidemia: Exercise and healthy diet have been recommended. The suggested level of exercise is 60% volume of maximum oxygen consumption, e.g. pulse rate 100/min for 30min/day. Also, a reasonable alcoholic intake, a decrease in dietary purine and stopping smoking have been recommended. If the change in lifestyle does not improve his condition, Englucon (glibenclamide, 0.25mg daily) and Zyrolic (allopurinol, 200mg daily) should be prescribed.

(IN JAPANESE)

 クライアントはこれまで糖代謝異常として、運動などの生活習慣を変化させるように指導を受けていた。 しかし、入院時まで、特に生活習慣に注意を払ってきていなかった。
 最近、階段の昇降時に胸部不快感を認めるが、その他の訴えはない。
 今回の検査では、負荷心電図や心臓超音波では異常は認めなかったが、心筋シンチグラフィーでは、 運動負荷後のアイソトープの還流障害を認め、安静により回復したことから、狭心症と診断した。
 治療として、Herbesser (diltiazem hydrochrolide)3錠/日投与した。
 糖尿病、高尿酸血症、高脂血症については、まず運動習慣を指導した。最大酸素消費量の60%を目安 として、脈拍100/分。30分・日を目標とした。なお、適正飲酒、過度のプリン体摂取の抑制、禁煙も 同時に実行することを求めた。
 なお、生活習慣の変容によっても病態が改善しなければ、血糖調節にはEuglucon (Glibenclamide) 1錠/朝 、尿酸調節には Zyrolic (Allopurinol) 2錠/日投与の予定。

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General Status (全身状態)

1) Body Measurement (身体計測)
ITEM VALUE IN JAPANESE
Body Height 169.0cm 身長
Body Weight 76.3Kg 体重
Degree of Obesity 21.4% 肥満度
Body Mass Index BMI 26.7  
Ratio of Body Fat 25.8% 体脂肪率
Comment:obese (肥満)

2) Blood Pressure: 126/80 (血圧)

3) Physical Findings: within normal limits (身体的所見異常認めず)

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Chest and Respiratory System (胸部、呼吸器)

1) Chest X-ray Film: no pathological findings (胸部レントゲン写真:異常なし)

2) Pulmonary Function Test (呼吸機能検査)
ITEM VALUE NORMAL
RANGE
IN JAPANESE
Vital Capacity (VC) 2.76L 肺活量
% Vital Capacity 80.7% {<80%} %肺活量
Forced Expiration Volume 1.0 (FEV1.0) 2.12L/sec 1秒量
% Forced Expiration Volume (FEV1.0%) 76.8% {<70%} 1秒率
Maximal Midexpiratory Flow (MMF) 1.82L/sec 最大平均呼気速度
% MMF 55.0%
Peak Flow Rate (PFR) 7.84L/sec 最大流速率
V50 2.43L/sec 50%FVCにおける最大呼出速度
V25 0.49L/sec 25%FVCにおける最大呼出速度
V50/V25 5.02
V25/HT 0.28 V25/身長比
Comment: within normal limits (診断:異常なし)

3) Sputum Cytology: not done (喀痰細胞診:施行せず)

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Cardiological Examination (循環器)

1) Electric Cardiography (心電図)
Double Master Test : no abnormal findings
(負荷心電図:異常認めず)


2) Ultrasonic Cardiography (心臓超音波検査)

Movement of Cardiac Wall: good (壁運動:良好)
Thickness of Cardiac Wall: normal (壁厚さ:正常)
Valvular Insufficiency and Stenosis: (-) (弁逆流及び狭窄:認めず)


3) Myocardial Scintigraphy with Thallium (心筋シンチグラフィー)
Ischemic change of anterior myocardium
(前壁に心筋虚血性変化)

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Gastroenterological Examination (消化器)

1) Stool Occult Blood: negative (便潜血反応 陰性)

2) Gastroscopical Examination (上部消化管内視鏡検査)
Endoscopical Diagnosis: atrophic gastritis
(萎縮性胃炎のみ)



3) Sigmoidoscopical Examination (下部消化管内視鏡検査;S字状)
Endoscopical Diagnosis: no pathological findings
(異常認めず)


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Hepatobiliary Tract (肝胆道膵等)

1) Abdominal Ultrasonography (腹部超音波検査)
Comment: no abnormal findings (異常なし)

2) Abdominal Computed Tomography (腹部CT検査)
Comment: no abnormal findings except small hepatic cyst (arrow)
(矢印の小さな肝嚢胞以外は正常)


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Blood Chemistry (血液生化学的検査)

1) Hematology (血球検査)
ITEM VALUE NORMAL
RANGE
IN JAPANESE
Red Blood Cell 456x10000/ml {410-530} 赤血球数
Hematocrit 44.0% {39-52} ヘマトクリット
Hemoglobin 14.5g/dl {14-18} ヘモク゛ロヒ゛ン
Mean Corpuscular Volume (MCV) 96.7fl {88-99} 赤血球平均容積
Mean Corpuscular Hemoglobin(MCH) 31.9Pg {29-35} 赤血球平均色素量
Mean Corpuscular Hemoglobin
Concentration(MCHC)
33.0g/dl {31-36} 赤血球平均色素濃度
White Blood Cell 6910 /ml {4000-8000} 白血球
Neutrophilic Leucocyte 67.9% 好中球
Lymphocyte 23.3% リンパ球
Monocyte 5.0% 単球
Eosinophilic Leukocyte 1.8% 好酸球
Basophilic Leukocyte 0.5% 好塩基球
Leukocyte Unclassified 1.6% 分類不能
Thrombocyte 19.3x10000/ml {16-35} 血小板
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2) Liver Function Test and other (肝機能検査、膵機能検査 蛋白分画)
ITEM VALUE NORMAL
RANGE
IN JAPANESE
Serum Total Protein 6.5g/dl {6.8-8.6} 血清総蛋白
Serum Albumin 3.7g/dl {4.0-5.4} 血清アルブミン
Serum Aspartate Aminotransferase (AST or GOT) 25U/L {11-34}
Serum Alanine Aminotransferase (ALT or GPT) 37U/L {4-37}
Serum Gamma-Glutamyl Transpeptidase (GGTP) 73U/L {5-40}
Serum Lactate Dehydrogenase (LDH) 339U/L {286-561}
Serum Alkaline Phosphatase (Al-Pase) 118U/L {95-278}
Serum Leucine Aminopeptidase (LAP) 138U/L {75-167}
Serum Choline Esterase (Ch-E) 259U/L {110-258}
Serum Amylase 76U/L {110-258} アミラーゼ
Serum Creatinine Phosphokinase 118U/L {47-212}
Serum Protein Fraction
Albumin 60.9%
Alpha-1Globulin 2.5%
Alpha-2Globulin 10.0%
Beta-Globulin 11.5%
Gamma-Globulin 15.0%
血清蛋白分画
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3) Electrolyte and Renal Function (電解質、腎機能)
ITEM VALUE NORMAL
RANGE
IN JAPANESE
Serum Sodium (Na) 140mEq/L {139-146} ナトリウム
Serum Potassium (K) 4.0mEq/L {3.6-5.0} カリウム
Serum Chloride (Cl) 102 mEq/L {99-108} クロール
Serum Calcium (Ca) 8.8mg/dl {8.4-10.2} カルシュウム
Serum Phosphorus (P) 3.7mg/dl {2.5-4.7}
Blood Urea Nitrogen (BUN) 12mg/L {8-23} 尿素窒素
Serum Creatinine 0.6mg/dl {0.6-1.1} クレアチニン
Serum Uric Acid 6.1mg/dl {3.6-8.0} 尿酸
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4) Urinalysis (尿検査)
ITEM VALUE IN JAPANESE
Protein ++ 蛋白
Glucose ++
Urobilinogen normal ウロビリノーゲン
Occult Blood + 潜血
Urine Sediment Red Blood Cell 2
/3 visual field
赤血球2/3視野
White Blood Cell 2
/3 visual field
白血球2/3視野
Epithelium(-) 上皮
Hyaline Cast 3
/all visual field
円柱3/全視野
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5) Lipid (脂質)
ITEM VALUE NORMAL
RANGE
IN JAPANESE
Serum Total Cholesterol 203mg/dl {136-200} 総コレステロール
Serum High Density Lipoprotein-Cholesterol 37mg/dl {42-68} HDL-コレステロール
Serum Tryiglyceride 494mg/dl {40-150} 中性脂肪
Serum Phospholipid 245mg/dl {154-246} 燐脂質
Serum Low Density Lipoprotein (LDL) 493mg/dl {179-465}
Serum Very Low Density Lipoprotein (VLDL) 669mg/dl {78-208}
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6) Glucose metabolism (糖代謝)
ITEM VALUE NORMAL
RANGE
IN JAPANESE
Fasting Blood Sugar (FBS) 84mg/dl {60-110} 食前時血糖
Glycosylated Hemoglobin A1 (HbA1) 10.4% {5.7-7.3} グリコヘモグロビンA1
Glycosylated Hemoglobin A1C (HbA1C) 9.5% {5.0-6.4} グリコヘモグロビンA1C
75g Glucose Tolerance Test
Before 60 Min 120 Min
Glucose 84 mg/dl 257 mg/dl 210 mg/dl
Urine Sugar 12 mg/dl 98 mg/dl 1306 mg/dl
Insulin 4.7 uM/ml 42.9 uM/ml 42.2 uM/ml
75g 糖負荷試験
Comment: Diabetes Mellitus (糖尿病)
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7) Serologic and immunologic examination (感染、免疫)
ITEM VALUE NORMAL
RANGE
IN JAPANESE
Blood Type B Rh(+) 血液型
Hepatitis B Antigen (HBsAg) negative HBs抗原 陰性
Hepatitis B Antibody (HBsAb) negative HBs抗体 陰性
Hepatitis C Antibody (HCV Ab) negative HCV抗体 陰性
Serological Test for Syphilis TPHA Method negative 梅毒反応TPHA法 陰性
C Reactive Protein (CRP) <0.5 mg/dl {<0.5}
Rheumatoid Factor <10IU/ml {<10} リュウマチ因子
Carcinoembryonic Antigen (CEA) 2.1ng/ml {<5.0} 癌胎児抗原
Alpha-FetoProtein (AFP) 3.5ng/ml {<20} α胎児性蛋白

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Neurological Examination (神経系)

Magnetic Resonance Imaging: no abnormal findings
(MR画像:異常認めず)


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Examination of Eye (眼科)

Visual Acuity Right Side: 0.7(1.2x+1, OD: cyl+0.5DA170) (視力 右)
Left Side: 0.7(1.5x+1.OD: cyl+0DA180) (視力 左)
Comment: myopic astigmatism (遠視性乱視)
Optic Disc: no abnormal findings (眼底異常なし)

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Otolaryngological Examination (耳鼻咽喉科))

Hearing Acuity: not disturbed (聴力低下なし)
Comment: within normal limits (異常なし)

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Urological Examination (泌尿器科)

Comment: Mild Bilateral Prostate Hypertrophy (前立腺肥大軽度)