英语查房教学(病例实战)

家族史
Family History
父母双亡， 死因不详 家族中无类 似疾病患者 否认家族遗 传病病史
It has not been found similar disease in his family. Deny history of family heritage disease. His parents were died, the reason has not been clear.
现病史
Present Health History
No nausea and 无头晕、恶心、 vomiting, chest pain, 呕吐及晕厥, dizzy, faint . 无胸痛 休息后可缓解 These symptoms can be relieved by rest.
现病史
现病史
Present Health History
缘于32年前查体发现心 The patient had cardiac murmurs 32 脏杂音，患者始终无症 years ago, but he was 状。 asymptomatic. 自5年前经常于劳累或 He felt palpitation after fatigue or 饮酒后感心悸，伴轻度 alcohol intake 5 胸闷 years ago, sometimes accompanied by chest discomfort.
Cardiomyopathy) on July 2005. Beta blockers and calcium channel blockers were used. The haemodynamy must be observed.
既往史
Past Health History
否认冠心病、糖尿 病病史 否认肝炎、结核等 传染病史 否认手术外伤及输 血史 无药物过敏史 Deny history of CAD ,diabetes mellitus. Deny history of heritage family disease Deny history of surgical operations, injuries and blood transfusion. No medicine allergy
入院查体
physical examination
T36.5℃ P69次/分， R18次/分 BP120/80mmHg 发育良好 一般情况好，双肺呼吸 音清，未闻及干、湿性 罗音
T:36.5℃, HR:69 b/m, R:18t/m, Bp 120/80mmHg, Developed well
Present Health History
2005年6月 动态心电图显示频发 多型室性早搏和阵发 性室速 给予口服胺腆酮治疗 超声心动图提示左室 流出道压力阶差高, ΔPG＝113mmHg
Continuous ECG revels premature ventricular contractions and paroxysmal ventricular tachycardia on June 2006. Oral Amiodarone was given him to control them. Echocardiography shows left ventricle hypertrophy, left ventricle outflow was narrow. ΔPG is 113mmHg.
现病史 Present Health History
2005年7月明确诊断为肥厚型 He was diagnosed as 梗阻性心肌病 HCM(Hypertrophic 会诊决定暂时应用β-受体阻 滞剂和钙拮抗剂行药物治疗 观察血流动力学，如左室流 出道压差降低，则继续药物 治疗，如左室流出道压力阶 差降低不明显，考虑射频消 融结合起搏治疗。
Generally speaking, he is in good condition .
Fra Baidu bibliotek院查体
physical examination
心前区无异常隆起，心尖
搏动于左锁骨中线外0.5cm， 无细震颤，心界增大，心 率69次/分，律齐 主动脉瓣听诊区可闻及34/6级收缩期吹风样杂音
Nursing Teaching Round 护理教学查房
WARD 17
南十七
Case Report 病例报告
Patient Mai Mai Ti, male, 买买提·艾山，男， 58 year-old ,was born in xinjiang. 58岁，新疆籍新疆 He was admitted to the 军区副政委。 hospital on March 7th 主因发现心脏杂音 2007. 32年，发作性心悸 Chief complaint: 5年于2007年3月7 He has had cardiac 日入院。 murmurs for 32 years, Palpitation for 5 years.
个人史
Personal History：
Has never been to epidemic area, deny 生于原籍，长期居住新 history of poison 疆，到过全国各地 touching. 否认疫区居住史，否认 化学毒物及放射性物质 Has history of smoking for many years, he has 接触史。有吸烟史数十 already quit smoking. 年，已戒烟，偶尔饮酒， Drinking occasionally. 无明确规律。 已婚，配偶子女均体健 His wife is healthy. The two daughters are also 大学文化程度 healthy. Bachelor degree.