病历格局范文(国外英文资料).docVIP

病历格式范文 XXX male, 55, 2008-12-5 married The 2008-12-5 han Beijing driver The patients and their families Intermittent fever for 1 year, the discovery of double lung nodules is reliable in August Patients with 7 years of intermittent fever, than after catch cold catch cold, Tmax38 °, cough, I have a yellow phlegm, difficult to produce, haemoptysis, night sweats, fatigue, shortness of breath after activities, intermittent temperature can drop to 3 to 4 days after normal, 07 these symptoms appear 4-5 times, did not make a diagnosis and give treatment. 88-4 cataract surgery, preoperative CXR is seen in the right lung and left lung and left lung, and the aorta. UCG: left room high voltage; Liver full and kidney: ALT6U/L, ALB42g/L, GGT28U/L, ALP56U/L, LDH180U/L, K4.3 mmol/L, Na140mmol/L, ADA13U/L. Routine blood: WBC6.18-10 ^ 9 / L, HGB124g/L, PLT239 * 10 ^ 9 / L. Urine routine: GLU3mmol/L, PRO (-), no fever, no sweat, no coughing, no coughing, no hemoptysis, no treatment. 08-7 patients after catch cold catch cold fever, Tmax38 ° C, cough, sputum occasionally, as the yellow phlegm, fearless cold, shivering, haemoptysis, night sweats, fatigue, difficulty breathing, no activity reduced endurance, and in the community hospital, CXR tip: ueno to go right lung lesions is aggravating, give azithromycin anti-infection treatment temperature is normal in 2 to 3 days. Posterior 08-11-6 review chest CT can be seen with small nodules in the middle and lower lung, partially visible cavity formation, and no significant thickening of the pleura. 08-11 in our hospital outpatient treatment, check: blood routine: WBC5.07 * 10 ^ 7 / L HGB128g/L PLT228 * 10 ^ 9 / L. ESR7mm/h; Tumor indicators: PSA, AFP, CEA, CA199, CA242, CA125 normal; Tb-ab: (-); Abdominal B: visible liver calcification. For further diagnosis and treatment of the income breathing division. Have disease, patients with spiritual food can sleep, urine normal, 4 kg weight gain, dry mouth, dry eye, no hair loss, skin rashes, matt