内科完整病历范文（Internal medicine complete medical record）.docVIP

内科完整病历范文（Internal medicine complete medical record） Internal medicine complete medical record Admission case history Name Xin Zhiqiang, work unit, occupation Sex address, No. 716, Fengyang Road, Shanghai Age 60 years, admission date 2008-3-11, 10:00 Married history take the date of 2008-3-11, 10:00 Birthplace, Shandong Pingyuan County, medical history, 2008-3-11, 10:00 I am the author of the disease The patient complained of recurrent palpitations, shortness of breath, swollen tired after more than 22 years, increased 2 more than a month. The history of patients from 1972 to 1976 between the camp and field often often fever, sore throat, and often feel big jointofextremity wandering without pain, swelling and movement disorder. Since 1968, it has been found that both eyes have swollen eyelids and swollen legs in the afternoon and evening. Without special treatment. In 1980, from the brisk walk, 0.5km, feel chest tightness and palpitations, rest for a while, that can ease. After 1986, brisk walking 200m, feeling heart palpitations, shortness of breath; at the same time, susceptible to cold, even in the sputum with blood in severe coughing. Since 1983, repeated paroxysmal nocturnal dyspnea, forced to sit 1 hours gradually ease, no pink foam sputum, still insist on work. After 1988, the night often cannot lie, or only to sit at the same time, upper abdominal fullness, anorexia, persistent lower limb edema, oliguria, palpitations, shortness of breath after feeling, not to work. After 1990, edema obviously increased, from the calf to the waist, urine volume decreased significantly, 400 to 500ml daily, taking diuretic effect is poor, abdominal distension, heavy, abdominal swelling gradually. No urine color, deep yellow and itchy skin. Still feeling chest tightness, heart palpitations, shortness of breath and rest. In 1970 as rheumatic heart disease in hospital diagnosis, 1976 was found to have atrial fibrillation, after long-term use of digoxin, combined with diuretics, v