呼吸科英文病例.doc

精品文档 Medical Records for Admisson General information6欢迎下载6欢迎下载6欢迎下载。Name: Du xuechunAge: 52Sex: MaleRace: HanNationality: ChinaAddress: Room.479, Building.11, Station north Road, Changsha, Hunan. Occupation: managerMarital status: MarriedDate of admission: Dec 17th, 2014, 16:00Date of record: Dec 18th, 2014, 15:32Complainer of history: Du xuechun Reliability: ReliableChief complaint: Cough and expectoration for one month, and shortness of breath after the event for half a month.Present illness: The patient felt itchy throat and coughed in mid-November 2014 after catching a cold. It is a paroxysmal cough relieved at night and occurred repeatedly in a moderate degree usually with white frothy sputum easily coughed. He didnt have fever, chest tightness and pain and shortness of breath. After taking medicine from Chinese medicine practitioners, he felt shortness of breath especially when he went upstairs and walked fast. Other symptoms still existed. On Dec 13th, 2014, the patient came to our outpatient and was diagnosed “lung infection with tuberculosis”. During Dec 14th to Dec 16th, 2014, the patient went to Chest Hospital of Hunan province and was diagnosed fungal infections and Alveolar proteinosis. Now to seek further therapy the patient was accepted to our department because of “unknown of lung disease”. Since onset, her appetite was good, and both her spiritedness and physical energy are good. Defecation and urination are normal. Past history The patient is healthy before. No history of operative diseases. No history of infective diseases. No allergy history of food and drugs. System review Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness.Personal history He was born in Hunan and almost always lived there. His living conditions were good. No bad personal habits and customs. Quitting smoking 10 years and have regular life.Obstetrical history: He married at 26, had a daughter. His daughter and wife are healthy.Family history: No similar family history and special medical history.Physical examinationT 36.7, P 96/min, R 18/min, BP 140/108mmHg. He is well developed and moderately nourished. Active position. His consciousness was clear. His face was cadaverous and 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 found enlarged.Head Cranium: Hair was black and white, 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 nares flaring. No tenderness in nasal sinuses. 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 reactions to light were existent. Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. 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 was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally. Lungs: Respiratory movement was bilaterally symmetric with the frequency of 18/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. Breath sound is rough. 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 96/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not examedInvestigationXiangya hospital (Dec 13th, 2014)Blood-Rt: WBC 9.9109/L, N 32.3%, L 53%, RBC 4.851012/L, Hb 153g/L, PLT 144109/L.Hepatitis B three pairs: HBsAg, HBeAg and HBcAb were positive, and others were negative.History summary1. Patient was male, 52 years old2. Cough and expectoration for one month, and shortness of breath after the event for half a month. 3. No special past history.4. Physical examination: T 36.7, P 96/min, R 18/min, BP 140/108mmHg Superficial lymph nodes wer