胸腔内科标准病历范本.doc

胸腔內科標準病歷範本 Case 1 1.主述：Non productive cough and intermittent fever for 3 weeks. 2. Present illness This 32 years old man of no systemic disease suffered nonproductive cough and intermittent fever for 3 weeks. The associated symptoms and onset were heralded by a flu-like illness with fever, malaise and fatigue. Dyspnea was light activity-aggravated but not sitting up-ameliorated. It sometimes associated with chest tightness, might last for more than half an hour but was not cold sweating-accompanied or resting-relieved. He lost about 6 kg within recent 3 weeks. His laboratory data disclosed leukoctyosis and elevated CRP level; physical examination, bilateral inspiratory rales; CXR, bilateral diffuse alveolar process over the lung fields. Under tentative diagnosis of community-acquired pneumonia, he was admitted to the chest ward for further appraisement and management. 3.住院主要臆斷：Community-acquired pneumonia, bilateral. 4.鑑別診斷:： Congestive heart failure with pulmonary edema Meatastatic lung cancer Pulmonary tuberculosis Chronic bronchitis with acute exacebation 5.住院診療計劃： Diagnosis plan: Sputum culture, Gram’s stain, AFS + TB culture,blood culture, Mycoplasma , follow up, pulmonary function test, cardiac echo, lung biopsy as needed. Therapeutic plan: Antibiotic treatment with Moxifloxacin 400mg qd ivd. O2 supply, symptomatic relief of supportive medication. Education plan: Mask wearing. 執行護理照護計畫. 住院診療計劃. Case 2 1.主述：Progressive hemoptysis for 10 days 2. Present illness This 78 years old woman of previous bronchiectasis for more than 15 years had pulmonary non-tuberculous mycobacterial (NTM) infection about 2 years. Anti-TB agents were prescribed for 2 months since Aug. to Oct. 2009. Besides, she was intubated in Aug. 2009 due to hemoptysis with acute respiratory failure. Intermittent dyspnic attacks and bloody phlegm were complaints for a long time. This time, the increased hemoptysis in recent 10 days was dyspnea-accompanied. Otherwise, there was no f