呼吸内科病历（Respiratory medical records）.docVIP

呼吸内科病历（Respiratory medical records） Department of respiratory medicine medical records - Example Admission record Lin Changsheng, male, 68 years old, married, by Zhejiang Province, Han nationality, Shanghai Yue Opera retired musician. Because of repeated cough, expectoration, shortness of breath, palpitation 22 years, swelling for 2 years, increased half, on the afternoon of December 7, 1991 outpatient hospital. Patients since 1969, each attack lasted 7~10 days, after tetracycline, citrate, Victoria, Jingning (Ke Biqing) and other drugs, can be improved. Episode 2 ~ 3 times a year, in the late autumn and early winter time. Work and life are not affected. Since 1981, cough, expectoration aggravated, sooner or later, especially drama, sometimes accompanied by shortness of breath. Daily sputum volume of about 10 ~ 20ml, white foam, penicillin and other drugs to ease the treatment. The symptoms are relieved by more than 3 months and warmer weather. Upstairs, hard work, a flustered, shortness of breath, but daily life can take care of themselves. Many times to the district hospital, diagnosed with chronic bronchitis, emphysema. Take cough, expectorant and antiasthmatic drugs regularly. In the winter of 1989, cough and white foam sputum continued throughout the year, and there was no obvious seasonality. When there is fever, more than 38 degrees celsius. The daily sputum volume of 50 ~ 60ml, the amount of sputum fever can be increased to about 100ml, and the Yellow purulent sputum, dyspnea, asthma, heart palpitations, edema of lower limbs. Moving the shortness of breath, palpitation aggravated. I was hospitalized three times in the city * * hospital, and all of them were diagnosed as chronic bronchitis, emphysema and pulmonary heart disease. By penicillin, streptomycin, aminophylline, hydrochlorothiazide, triamterene, drug treatment, palpitation, dyspnea improved, edema subsided. After discharge, daily life can not completely take care of themselves, sometimes lying and f