英文完全病例书写(呼吸科)

Medical Record of AdmissionName: Guo XX Sex: MaleAge: 41 years old Marital status: MarriedRace: Han Occupation: WorkerPlace of birth: Chenzhou City, Hunan provinceAddress: Linwu County, Chenzhou City, Hunan provinceDate of admission: 11：12 AM, 05,12,2014 Date of records: 17:20PM, 05,12,2014Complainer: Guo XXChief complaint: Cough for two months, and tachypnea and chest pain for one month.History of present illness:The patient have no obvious cause cough in October this year, a small amount of white sticky sputum, blood in the sputum, no10th, the patients with fever, the highest temperature of 39.2 degrees, tachypnea, chest pain, hence clinic in Linwu county people's hospital, the number of WBC has been checked a little bit high, chest CT shows on the left side of the massive pleural effusion, a little right lung infection, diagnosis "left pleural effusion, pleurisy" to fight infection (specific drug use is unknown), no significant improvement in symptoms. Then transferred to the first people's hospital of Chenzhou, also the number of WBC has been checked a little bit high, calcitonin original high, c - reactive protein and blood sedimentation increase fast, pleural effusion as exudates, diagnosed as "check the left pleural effusion due to: tuberculosis likely, double lung infection", to the amp south + levofloxacin anti-infection, fever back slightly, but still has a low thermal afternoon, in the 2014-11-20 to diagnostic anti-tuberculosis (quadruple the chemotherapy plan: isoniazid 0.3 qd + rifampicin 0.45 g qd + pyrazinamide 0.5 tid + ethambutol 0.75 qd), patient with no fever, cough, chest pain, were compared with the previous improved patient for diagnosis hence to our hospital. Since the onset of the patient with a good spirit, appetite, sleep, and fever, occasionally cough, blood in phlegm, the feces and urine are both normal, regular anti-tb drugs, weight did notsignificantly reduce.Past history: Ever healthy. Denied the history of "hypertension" and "coronary heart disease", "diabetes". Deny "hepatitis b" "TB" "typhoid fever and other infectious disease and exposure history, deny the history of trauma, surgery and blood transfusion, denied drugs and food allergy, history of vaccination is unknown.Systematic review:Head and facial: No history of visual impairment, deafness, tinnitus, dizziness, nose bleeding, toothache, bleeding gums and voice hoarse.Respiratory system: History of cough, expectoration, hemoptysis, difficulty breathing, tachypnea, fever, chest pain, night sweats.Circulatory system: History of tachypnea, no palpitation, lower limb edema, the area before the heart pain, blood pressure, syncope.Alimentary system: No history of belching, acid regurgitation, difficulty swallowing, abdominal distension, abdominal pain, diarrhea, vomiting, jaundice, hematemesis and melena.Genitourinary system: No history of urinary frequency, urgency, urine pain, waist pain, hematuria, dysuria, abnormality of urine, facial edema, genital ulcers.Endocrine system and metabolic: No history of fearless cold, afraid of hot, sweaty, fatigue, headache, palpitations, abnormal appetite, polydipsia, polyuria, edema, obesity.Hematopoietic system: No history of pale skin, dizziness, vertigo, bleeder petechial skin, lymph nodes, liver and spleen enlargement, bone pain.Neural system: No history of headache, dizziness, memory loss, skin feel abnormal sense or history of convulsions, the language barrier, disturbance of consciousness. Kinetic system: No history of joint pain, trembling, convulsions, paralysis, paraesthesia.Mental state: No history of hallucinations, delusions, disorientation, mood disorders. Personal history: Born in origin, not to foreign residents, denied "schistosomiasis epidemic" water and exposure to toxins, denial of serious trauma history and history of play, there are 4 years of exposure to dust, not smoking, not drinking alcohol.Marital history: Married at 33, have a son and a daughter, spouse and children both healthy.Family history: There was no similar or specific medical history in his families.Physical examination: T 37.8℃, P 107/min, R 20/min, BP 120/70mmHg. He is well developed and moderately nourished. Active position. His consciousness was clear. the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. The superficial lymph nodes were not found enlarged. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent. No tenderness in mastoid area. Pharynx was not congestive. Tonsils were not enlarged. The neck was soft, jugular veins were not visible and the pulsation of carotid arteries were normal. Thyroid was not enlarged. Trachea was in midline. Chest veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thoracic symmetry on both sides. The tactile fremitus of right lung is normal, right lung percussion sounds were clear, right lung was clear breathing sound. No rhonchus. No moist rales. The tactile fremitus of left lung is reduced, the respiratory movement degrees. No pleural friction fremitus.The left lung percussion were solid sounds and The left lung respiration disappeared. No bulge in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line. No thrills and pericardial friction sound. Border of the heart was normal. Heart rate 107/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen was flat and soft. No abdominal wall varicosis. Gastrointestinal type or peristalses were not seen. No tenderness or rebound tenderness in the abdomen.Liver and spleen was untouched. No masses. Shifting dullness negative. Fluid thrill negative. No pain in renal regions when percussion. Borborygmus was normal, 4/min. No vascular murmurs. Genitourinary system and rectum were not examined. No articular swelling. Free movements of all limbs. The muscular strength tension of limbs were normal. No edema. Physiological reflexes were existent without any pathological ones.Auxiliary examination:Diagnosis: Check the left lesion and pleural effusionTuberculosis likelyTumor wait for exclusionPhysician sign: Zhang Lian。