外科3(国外英文资料).docVIP

内科3 Complete case Name: tao hai people: han Gender: male native: xiang Age; Career 70: retired worker Marriage: married: XXXXX Admissions date: 2009-7-5 21:10 record date: 2009-7-5 23:10 Medical history: the patient is personally reliable: reliable Main complaint: two years of onset of chest pain, double leg edema in half, breathing for one day. Present history: the patient complained of sudden chest pain when he was tired two years ago, and the severe pain of the continuous sharp knife, especially in the front area of the heart, can be radiated to the left shoulder and neck. Sweat and sweat. No symptoms such as spasms and mental disorders. Hence (data) at a local hospital, in order to acute anterior wall myocardial infarction conservative treatment in hospital (plan specific diagnosis and treatment and medication are unknown) 2 weeks later, the above symptoms improved discharged from hospital. Since then, the pain of the chest pain, more and more fatigue, the meal has to be concerned, rest for 5 minutes or so can self-alleviate, did not give medicaments treatment. Six months ago began to have no obvious cause a double lower limbs can be pitting edema associated with fatigue, expiratory dyspnea, especially in the activity after intensifying, nocturia 2 ~ 3 times, at home since the (specific medical name unknown), a dose of antibiotics can reduce symptoms. The recent shortness of breath is getting worse, and you cant lie flat at night. A day before the night, I was very sweaty and sweaty. I had a small amount of pink frothy sputum, and I had to go to the emergency department of our hospital. Emergency physical examination: BP140/75 MMHG, R22 times/min, P102 times/min, the double eyelid edema, chemosis, double lung breath sounds crude, double audible and a large number of dry wet lung sound, apex audible and diastolic gallop, liver rib under 3 cm, qualitative, with light pressure, double lower limbs can be pitting edema. The suspicious diagnosis is the heart failure