英文病历englishi case (AMI).doc

Medical Records for AdmissionComplete HistoryMedical Number: 136049General information：Name：* Occupation：IntendantSex：Male Educational level：UndergraduateAge：46 Date of Admission：16Pm, Nov 15,2012Nationality：Han Date of Record：17:30Pm, Nov 15, 2001 Nativity：GuangXi Informant：Patient himself and his wifeMarital Status：Married Reliability：ReliableDepartment of work：Xinjiang Construction Engineering Group CorporationAddress：Room201,Unit4,11th Building,Taixiu Residential, Altay RoadChief Complaints：Repeated chest pain four days, aggravation for half an hour.Present Illness：The patient had felt precordial pain after drinking 4 days ago, accompanying by upper limbs soreness, fatigue, for 30 minutes to ease. Afterwards, in symptoms after drinking relapse, did not undergo treatment. Around 14:00 today, the patient felt chest pain again when driving, and the symptoms significantly worse than before, accompanying chest tightness, breathlessness, profuse sweating, soreness and weakness of the upper limbs, and feeling of impending death. For the symptoms continued for half an hour had not alleviated, the patient visited the emergency department. There was ST segment elevation across the precordial leads(V1-V6), and in leadsand avL on the surface ECG at that time. Received emergent treatment, the patient sudden lost of consciousness at 14:50, and ventricular fibrillation was observated on cardiac monitor. Given electric defibrillation , the patient was recovery of consciousness, but ventricular fibrillation occurred again and again. After received 13 times electric defibrillation, the patient maintains stable vital signs, and transferred to the coronary care unit.Past History：The patient has suffered from the 8-year history of “hypertension”, with the most blood pressure of 170/120mmHg, and 1-year history of “gout”. He denied any history of infectious diseases including “hepatitis”， “tuberculosis” and “typhoid fever” etc There was no related history of operation and traumaHe had a history of allergy to SulfanilamideReview of Systems：Respiratory System：No pharyngalgia；no chronic cough or haemoptysis；no thoracalgia；no afternoon fever or night sweatsCirculatory System：No breathlessness on exertion；no dizziness and persistent headache；no syncope and amaurosisDigestive System：No sour regurgitation and dysphagia；no chronic abdominal ache，diarrhea and vomiting；no jaundice，hematemesis and melenaUrinary System：No past history of edema and proteinuria；no pollakiuria；no urgency and painful micturition；no visible hematuriaEndocrine and Metabolic System：No irritability，hidrosis or profound fatigue and headache；no impaired vision，exceeding thirsty and polyuria；no excessive hairiness or hair loss；no pigmentation and sexuality change Hematopoietic System：No pale skin，no dizziness，blurred vision and tinnitus；no impairment of memory；no petechia and jaundic over the skin and mucosa；no lymph node，liver and spleen enlargement；no abnormal bony painMuscle，bone and Joint System：No unusual pain，redness and swelling of the joints； no deformity of joints；no limbs and trunk limitation on motion；no myoasthenia and myoatrophyNervous System：No persistent headache and syncope；no memorial impairment or speaking obstacle；no insomnia and consciousness obstacle；no paresthesia of skin；no paralysis and convulsionMental Status：No hallucination，delirium and orientation obstacle；no abnormal emotionPersonal History：The patient was born in XingjiangHe has smoked an average of 40 cigarettes daily for 30 years. Patients has a history of drinking more than 10 years, daily alcohol consumption of 50-250ml.Marital History：She married for 26 yearsHis wife and son is in good health with happy family lifeFamily History：The patients father died from cancer. His mother is suffering “hypertension, coronary heart disease and diabetes ”. His brother is suffering “coronary heart disease”.There was no history of other familial hereditary diseases.Physical ExaminationT：36.4 P：98/min R：18/min BP：109/74mmHg W：unmeasuredGeneral condition：Normally developed，moderately nourished；active position，alert and cooperativeSkin and Mucosa：Normal temperature； no jaundice，eruptions or bleeding spots； no pigmentation，mile to moderate edema of bilateral eyelids and lower extremiliesLymph glands：No superficial lymph nodes enlargementHead organ：Normal shape of head；hair black and shining with average distribution； no scarsEyes：Mild edema of eyelids；no bleeding spots of conjunctivano sclerae jaundice；cornea clear，pupils round，symmetrical in size and acutely reactive to lightEars：Normal hearing；no purulent secretion of the external canals；no tenderness over mastoidsNose：No obstruction；no deviation of septum；no discharge or tenderness of antrumsMouth：Lips red without cyanosis；teeth in alignment，no carious teeth or gingival hemorrhage；pharynx injected；no enlarged tonsils seen；smooth and glossy tongue in midlineNeck：Supple without rigidity，symmertrical；no cervical venous distention；no abnormal carotid impulse；trachea in midline；no enlargement of thyroid glandChest：Symmetrical；thoracic breathing predominately；rhythm normalLung：Inspection：Equal breathing movements on two sidesPalpation： No difference of vocal fremitus over two sides；no friction rub feltPercussion：Resonant on percussion over both lungsThe lower borderof lungs lies on right mid-clavicular line at fifth intercostals space and subscapular line at ninth intercostal space and left scapular line at tenth intercostals spaceShifting degree 4cm Auscultation：Normal breath soundNo dry or moist rales audibleHeart：Inspection： No precordial protuberanceApex beat seen 1.5cm outside left mid-clavicular line at fifth intercostal spaceDiameter of impulse is 1.5cm. Palpation： No thrill or friction felt；no lifting impulse；apex beat observed on the same location as on inspectionPercussion：Enlarged dullness of heart bordersRelative dullness of heart borders measured as follow：Right(cm)Intercostal spaceLeft(cm)22.53445.06.5 *Distance between midstemal line and mid-calvicular is 8cm. Auscultation：Heart Rate：98/min；rhythm irregular；no gallop thythm；Diastolic and systolic murmur can not be heard . No pericardial friction sound audiblePeripheral Vascular Sign：Full pulse，rhythm regular；no paradoxical pulse and deficient pulse；no water-hammer pulse and gunshot sound；no capillary pulsationAbdomen：Inspection：Symmetrical；no abdominal distension or dilated veins；no skin rash or scar；no abnormal intestinal and peristaltic waves seenPalpation：Abdominal wall flat and soft without tenderness or rebounding tendernessNo succession splash and liquid wave thrill；no bladder distensionLiver，spleen and kidneys not palpablePercussion：No shifting dullness；mild tympanyDullness of liver borders within normal limitThe upper border of liver lies on right mid-calvicular line at fifth intercostal spaceNo percussion tenderness over the kidney regionAuscultation：Normal bowel soundsNo vascular murmur heardAnus and Rectum：No anal fissures or proctoptosis；no fistulous tract or hemorrhoidExternal Genitalia：Normal distribution of the pubic hair；normal development of external genitalia；no scars or ulcersSpine：Normal spinal curvature without deformities；normal movements；no tendernessExtremities：Moderate pitting edema are found over both legsNo clubbed fingers(toes)；no myoatrophy，varicose veins or fracture；no redness and swelling of joints；no tenderness or deformities of jointsMotor function normalNo limitation of joint movementNeurological Reflex：Dermatographism(-)Normal abdominal and bicipital muscular reflex；patellar and heed-tap reflex normal；Babinski sign (-)，Oppenhein sign (-)，Gordon sign (-)，Chaddock sign (-)，Hoffmann sign (-)，Kerning sign (-)， Brudzinski sign (-)Laboratory data (before admission)ECG: There was ST segment elevation across the precordial leads(V1-V6), and in leadsand avL. Reciprocal ST segment depression in the inferior leads (leads , , and avF).Summary of Case History1. The patient，*， male, Han，46，was admitted on Nov 15, 2012. 2. 8-year history of “hypertension”, and 1-year history of “gout”. Allergy to Sulfanilamide.3. Because repeated chest pain four days, aggravation for half an hour, the patient visited the emergency department. Received emergent treatment, the patient sudden lost of consciousness, and ventricular fibrillation was observated on cardiac monitor. After received 13 times electric defibrillation, the patient maintains stable