病例模板(国外英文资料).docVIP

病例模板 enterism Name: * * * contact telephone: 1370532 * * * * Gender: womens address: 302 units of the peoples road, no. 1, 4 Age: 66-year-old working unit: Marriage: married admission date: May 7, 2008, at 9:50 Occupation: worker record date: May 7, 2008 Nationality: the history of the han state: the patients family (dependability) Native place: Qingdao has a disease: the beginning of summer Main complaint: intermittent onset cough, expectoration of sputum, breathing for more than 30 years, aggravate 3 days. Hpi: patient private prosecution or outdoor activities, more than 30 years ago contact lampblack acuteness activity after coughing, coughing up phlegm, sputum volume, to white phlegm mixed with foam, easy to produce, from the environment and can alleviate after resting, not regular treatment, symptoms relief, has more than 10 years did not attack. Symptoms reappear in activity after more than ten years ago, cough, dry cough without phlegm, asthma suppress, can lay down at night to see a doctor in the hospital outpatient service, diagnosed as bronchial asthma, chronic bronchitis, gives anti-infection, smooth wheezing, expectorant remission after treatment (specific drug use is unknown). After repeated attacks, these symptoms in autumn and winter cold season, the gap in our clinic, giving to lixin anti-infection, ejector torin, aminophylline to smooth wheezing (such as treatment, medication after symptoms can alleviate or reduce obviously. In February last year because of illness to my family in the hospital, diagnosed as bronchial asthma, chronic bronchitis, chronic cor pulmonale, coronary heart disease, used to lixin, methylprednisolone, asthma, soak up the comfortable and love all happy hospital treatment for 10 days of symptoms. In the patients hospital, the long-term oral time (oral) is a 1-piece bid, and the relicorice tablet is 2 pieces of tid, and will be treated as needed. Three days ago have no obvious cause illness, patients with asthma suppress bosom