西医住院病历（Hospitalized medical records of Western Medicine）.docVIP

西医住院病历（Hospitalized medical records of Western Medicine） Name: XXX Occupation: Worker Gender: female address: XX, XX Road, XX Age: 44 years old, admission date: March 1, 1994, 10, nationality: Han record date: 10 March 1, 1994, birthplace: XX Province XX city history statement: patient himself Marriage: married reliability: reliable Chief complaint: palpitation, shortness of breath fatigue after 10 years, aggravated in 2 years, 3 days of fever and edema of lower extremity. History: fifteen years ago (1979) without obvious inducement, palpitation, shortness of breath appear tired after a short rest can alleviate. Once in Lanzhou Chengguan District Hospital, diagnosed with rheumatic heart disease, mitral stenosis and insufficiency (medication unknown). At that time able to do the general work, without special treatment. Two years ago, due to a cold cough, palpitation, shortness of breath, cough aggravating, thin white foam sputum, sometimes bloody sputum, color red, three days later due to massive hemoptysis, live in the city second hospital treatment (medication unknown), palpitations, shortness of breath loss, haemoptysis stops, then no symptoms of fever, chest pain and sweating. No edema of lower extremity. After minor work, feeling heart palpitations, shortness of breath, lower extremity edema, morning subside. Half a year ago, due to a cold fever, palpitation, shortness of breath, in addition to aggravate, and not supine, accompanied by abdominal distension, nausea, lower extremity edema, no joint pain. Once in the city hospital diagnosed as heart failure and flu and penicillin, intramuscular injection of 800 thousand U each time, 2 times a day, streptomycin intramuscular injection every time. .5g, 2 times a day, take digoxin every time. .5mg, two times a day, three days later, heart palpitations, shortness of breath and reduce urine! The swelling disappeared and the body temperature returned to normal. After a day of dig, heating back a little, but the aggravati