诊断学：病历范例（英文）.docVIP

PAGE THE AIDED TEXTBOOK OF DIAGNOSTICS THE EXAMPLES OF ADMISSION NOTE 2012.2 CATALOG RESPIRATORY SYSTEM NOTE………………………2-10 CARDIOVASCULAR SYSTEM NOTE…………………11-20 DIGESTIVE SYSTEM NOTE…………………………21-27 URINARY SYSTEM NOTE……………………………29-37 HEMATOLGIC SYSTEM NOTE ………………………38-45 ENDOCRINOLOGIC SYSTEM NOTE…………………46-53 ADMISSION NOTE PATIENTS NAME: Li An BIRTH PLACE: Dali, SEX: Male ADDRESS: No. 176, Yue Xiu Nan Road, DATE OF BIRTH: Jan 5th, 1964 DATE OF ADMISSION: June 8th, 2007 RACE: Han DATE OF HISTORY TAKING: June 8th, 2007 MARITAL STATUS: Married SOURCE OF HISTORY: Patient OCCUPATION: Auto repair worker RELIABILITY OF HISTORY: Reliable CHIEF COMPLAINT: Intermittent shortness of breath for 20 years and recurring attack for 1 week HISTORY OF PRESENT ILLNESS: The patient, a 43-year-old male, complained of recurrent shortness of breath over the past 20 years. Attacks often occured in the early morning or in cold weather and could be triggered by eating eggs. The symptom usually resolved in 10 minutes without treatment. In the incipient stage, the shortness of breath was not accompanied with cough and sputum and he could lie down without increasing difficulty in breathing. However, the symptom had been aggravated since 10 years before. He reported recurrent shortness of breath accompanied by chest tightness, wheezing, cough, sneezing, itchy nose and sweating. He was more comfortable in sitting position than in supine position during attacks and symptoms usually were relieved in a few hours after expectoration of frothy sputum. Poor appetite and tiredness were noted during attacks but there had been no fever, palpitation, hemoptysis, pink frothy sputum and chest pain. He complained of shortened intervals between episodes and prolonged duration of attacks over the past years. He was quite normal between attacks. He was admitted to Guanzhou First Municipal Peoples Hospital seven years ago and diagnosed as “asthma”. Cimaterol could relieve the symptoms quickly. However, si