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Medical Records for Admisson
General information
Name:
Du xuechun
Age:
52
Sex:
Male
Race:
Han
Nationality:
China
Address:
Room.479,
Building.11,
Occupation:
manager
Marital status:
Married
Date
of
admission:
Dec
17th,
2014,
16:00
Date of record:
Dec 18th, 2014, 15:32
Complainer
of
history:
Du
xuechun
Reliability:
Reliable
Station north Road, Changsha, Hunan.
Chief complaint:
Cough and expectoration for one month, and shortness of
breath after the event for half a month.
Present illness:
The
patient
felt
itchy
throat
and
coughed
in
mid-November
2014
after
catching
a
cold.
It
is
a
paroxysmal
cough
relieved
at
night
and
occurred
repeatedly
in
a
moderate
degree
usually
with
white
frothy
sputum
easily
coughed.
He
didn’t
have
fever,
chest
tightness
and
pain
and
shortness
of
breath.
After taking medicine
from
Chinese
medicine practitioners,
he
felt
shortness of breath especially when he went upstairs and walked fast. Other
symptoms
still
existed.
On
Dec
13th,
2014,
the
patient
came
to
our
outpatient
and
was
diagnosed
“lung
infection
with
tuberculosis
”
.
During
Dec
14th to
Dec
16th,
2014, the
patient went to
Chest
Hospital of
Hunan
province and was diagnosed fungal infections and Alveolar proteinosis. Now
to seek further therapy the patient was accepted to our department because
of
“unknown
of lung
disease”
.
Since
onset,
her
appetite
was
good,
and
both
her
spiritedness
and
physical energy are good. Defecation and urination are normal.
Past history
The patient is healthy before.
No
history
of
operative
diseases.
No
history
of
infective
diseases.
No
allergy history of food and drugs.
System review
Respiratory system:
No history of respiratory disease.
Circulatory system:
No history of precordial pain.
Alimentary system:
No history of regurgitation.
Genitourinary system:
No history of genitourinary disease.
Hematopoietic
system:
No
history
of
anemia
and
mucocutaneous
bleeding.
Endocrine system:
No acromegaly. No excessive sweats.
Kinetic system:
No history of confinement of limbs.
Neural system:
No history of headache or dizziness.
Personal history
He was born in Hunan and almost always lived there. His living conditions
were good. No bad personal habits and customs. Quitting smoking 10 years
and have regular life.
Obstetrical
history:
He
married
at
26,
had
a
daughter.
His
daughter
and
wife are healthy.
Family history:
No similar family history and special medical history.
Physical examination
T
36.7
℃
,
P
96/min,
R
18/min,
BP
140/108mmHg.
He
is
well
developed
and moderately nourished. Active position. His consciousness was clear. His
face was cadaverous and the skin was not stained yellow. No cyanosis. No
pigmentation.
No
skin
eruption.
Spider
angioma
was
not
seen.
No
pitting
edema. Superficial lymph nodes were not found enlarged.
Head
Cranium:
Hair was black and white, well distributed. No deformities.
No scars. No masses. No tenderness.
Ear:
Bilateral auricles were symmetric and of no masses. No discharges
were
found
in
external
auditory
canals.
No
tenderness
in
mastoid
area.
Auditory acuity was normal.
Nose:
No
abnormal
discharges
were
found
in
vetibulum
nasi.
Septum
nasi was in midline. No nares flaring. No tenderness in nasal sinuses.
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