英文病例 室上速.docx

Name:Sun XXSex:MaleAge:26Date of birth: 08/19/1987Occupation: /Nation: HanNationality: ChinaMarital Status: MarriedPlace of birth: /Residence?address:Harbin, HeilongjiangPostalcode: /Person provide history:Relationship with patients: oneselfReliable or not: reliable/s?wd=admission%20dateAdmission date: 2013-10-27 13:27chief complaint: Paroxysm of palpitations for 1 monthPresent history:The patient felt a fast heart beating with a sudden onset in 1 month ago.He felt regular thudding palpitations in the chest without a clear precipitating factor. During the palpitations, he didn’t feel any dyspnea, mental status change. Then he came to a hospital nearby and was done an EKG . The doctor had a diagnosis of PSVT(paroxysmal supraventricular tachycardia).The patient had a treatment with some verapamil and he felt good. In order to do the interventional therapry, the patient come to our hospital, and was adimitted as “Arrhythmias, paroxysmal supraventricular tachycardia”. During the whole disease process, this patient has got the sound diet and sleep, and the urine and stool remained good.Past history:Genetal health: fineInfectious disease: NoOperation history: NoTrauma history: NoAllergic history: NoBlood transfusion history: NoPMI: NoPersonal historyThe epidemic area: NoSmoke: NoQuit smoking: NoAlcohol: NoMenstrual history: Male menarche period:MaleMarriage history: marriageable age: 21 Spouse health: healthy Child health: healthyFamily historyFather health: healthy Mother health: healthyThe family history of infectious disease and hereditary diseaseNote:The history of?the?statements and?confirmation?and signature:Relationship with patients: Date to signature: Physical ExaminationVital sign: body temperature: 36.6℃ Pulse: 86/min Respiration20/min Bp: 120/804mmHgGeneral Appearance:Development:ortho-sthenic typenutrition:wellFacial features:normalExpression:naturalConciousness: awarePosition: activeGait: normalCooperate or not: cooperateSkin and mucosaColor: norma