中医住院病历(国外英文资料).docVIP

西医住院病历 Name: XXX occupation: worker Gender: female address: xx city xx road xx Age: admission date: age 44: March 1, 1994: the han record date: March 1, 1994: the history of xx city of xx: the patient Marriage: married reliability: dependability Chief complaint: after fatigue, the heart palpitation and gas for 10 years, aggravated 2 years, fever with lower leg edema 3 days. Present history: 15 years ago (1979) there was no obvious inducement, after fatigue the panic, the qi, the short rest can be relieved. He was diagnosed with rheumatic heart disease, mitral stenosis and insufficiency (unclear). At the time, I was able to do general work without special treatment. Two years ago, because a cold cough, heart palpitations, shortness of breath, cough phlegm thin white foam samples, sometimes blood in phlegm, bright red color, after three days because of big haemoptysis, live in the city after the second hospital (no use), heart palpitations, shortness of breath, hemoptysis stopped, then no symptoms such as fever, chest pain, and night sweats, lower extremity edema. After that, slight labor, the palpitations, the gas, the lower extremities, edema, the morning recede. Half a year ago, because of the cold fever, apart from the heart palpitations and the aggravation, and cannot lie flat, accompanied by abdominal distension, nausea, lower limb edema, no joint swelling pain. At one hospital clinic in this city, the diagnosis is heart failure, upper sense, the muscle penicillin each time 800 thousand U, a day 2 times, streptomycin muscle note, every time. 5g, two times a day, oral gogoxin every time. .5mg, two times a day, three days later, heart palpitations, gas to relieve, urine! Increase, edema disappear, body temperature return to normal. In the future, we will take the dioxin daily, but the fever will be a little more, but the palpitations and the aggravation will not lie flat and will be able to participate in daily activities. Temperature fluctuation in 37. Three day