呼吸科英文病例.docVIP

Medical Records for Admisson General information Name: Du xuechun Age: 52 Sex: Male Race: Han Nationality: China Address: Room.479, Building.11, Station north Road, Changsha, Hunan. Occupation: manager Marital status: Married Date of admission: Dec 17th, 2014, 16:00 Date of record: Dec 18th, 2014, 15:32 Complainer of history: Du xuechun Reliability: Reliable Chief complaint: Cough and expectoration for one month, and shortness of breath after the event for half a month. Present illness: The patient felt itchy throat and coughed in mid-November 2014 after catching a cold. It is a paroxysmal cough relieved at night and occurred repeatedly in a moderate degree usually with white frothy sputum easily coughed. He didn’t have fever, chest tightness and pain and shortness of breath. After taking medicine from Chinese medicine practitioners, he felt shortness of breath especially when he went upstairs and walked fast. Other symptoms still existed. On Dec 13th, 2014, the patient came to our outpatient and was diagnosed “lung infection with tuberculosis”. During Dec 14th to Dec 16th, 2014, the patient went to Chest Hospital of Hunan province and was diagnosed fungal infections and Alveolar proteinosis. Now to seek further therapy the patient was accepted to our department because of “unknown of lung disease”. Since onset, her appetite was good, and both her spiritedness and physical energy are good. Defecation and urination are normal. Past history The patient is healthy before. No history of operative diseases. No history of infective diseases. No allergy history of food and drugs. System review Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats.