英文肺栓塞病历

肺栓塞

General information

Name: Liyuzhen ` Age:42 years Sex: Female Race: Han Occupation: Free occupation Nationality: China Married status: married Address: Sanfu Road No.16, Jiamusi. Complainer of history: Patient herself Reliability: Reliable Date of admission: 11.am, September 26th , 2013 Date of record: 2.pm, September 26th,2013

Chief Complaint: Chest pain and dyspnea for 1 day, hemoptysis for 3 hours. Present illness: One days ago the patient suddenly started to chest pain and feel dyspnea after movement. It became more and more serious, so the patient went adjacent hospital. After some treatment, her symptoms were still. 3 hours ago, the patient got hemoptysis. So she came to our hospital. Since its coming on, she never felt headache, nausea, bellyache and her phlegm was few. Her spirit, sleep, appetite were not good. stool and urine were normal.

Past History: General health status: normal Operation history: thyroidectomy. Infection history: No history of tuberculosis or hepatitis. Allergic history: allergic to a lot of drugs such as sulfanilamide Traumatic history: No traumatic history

System review:

Respiratory system: No history of repeated pharyngodynia, chronic cough, expectoration, hemoptysis, asthma, dyspnea or chest pain.

Circulation system: No history of palpitation, hemoptysis, legs edema, short breath after sports, hypertension, precordium pain or faintness.

Digestive system: No history of low appetite, sour regurgitation, belching, nausea, vomiting, abdominal distension, abdominal pain, constipation, diarrhea, hemaptysis, melena, hematochezia or jaundice.

Urinary system: No history of lumbago, frequency of urination, urgency of urination, odynuria, dysuria, bloody urine, polyuria or facial edema.

Hematopoietic system: No history of acratia, dizziness, gingival bleeding, nasal bleeding, subcutaneous bleeding or ostealgia.

Endocrine system: No history of appetite change, sweating, chilly excessive thirst, polyuria, hands tremor, character alternation, obesity, emaciation, hair change, pigmentation or amenorrhea.

Kinetic system: No history of wandering arthritis, joint pain, red swelling of joint, joint deformity, muscle pain or myophagism.

Neural system: No history of dizziness ,headache, vertigo, insomnia, disturbance of consciousness, tremor, convulsion, paralysis or abnormal sensation.

Personal History: She was born in Hubei.She never smokes and drinks. No exposure history to toxic substances, and infected water.Her menstruation was normal.

LMP:13/9,2013

Family History: Her parents are living and well. No congenital disease in her family. Physical Examination: Vital signs: T 36.6`C , P 110/min, R 32/min,

BP120/70mmHg. General inspection: The patient is a well developed, well nourished adult female apparently in acute distress, unpleasant and cooperative. Skin: Normally