呼吸科Medical Records for Admisson.docxVIP

Medical Records for AdmissonGeneral informationName: ZHOU XubaoAge: 79Sex: MaleRace: HanNationality: ChinaAddress: Occupation: RetiredMarital status: MarriedDate of admission: Jun 9th, 2014Date of record:Jun 12th, 2014Complainer of history: patient himselfReliability: ReliableChief complaint: Cough and chest pain for nearly 1 month, with weakness.Present illness: The patient began to cough and feel chest pain nearly 1 month ago. It becomes more serious at night, sometimes, the patient is wakened with cough. The patient coughs without expectoration and hemoptysis. He doesn’t have fever, either. The chest pain worsened gradually. At first, it was needle-like pain on the right lateral thoracic wall, and it developed to double side pain around the area of inferior boundary of lung 5 or 6 days ago.The pain is associated with position, and it worsened with movement. On the morning of Jun 9th, 2014, the patient went to local hospital, the X-ray examination indicated moderate amount of right pleural effusion. The patient came to our hospital in the afternoon. OnJun 9th, 2014, the patient was treated with chest drainage of about 750ml (1.5 bags) bloody pleural fluid. No structural alternations were seen in echo and ECG.Since the disease coming on, the patient’s spirit,sleep was normal. Appetite decreased. Stool and urine werenormal, too.Past history30-40 years ago, the patient had gastrorrhagia for 3 times, cured.20-30 years ago, the patient had coronary artery’s disease, cured.The patient has goat for 3-4 years.The patient has hypertension for 2-3 years, and takes nifedipine regularly.History of transfusion: Denied.Allergic history: Allegic history of food and drugs is denied.Operation and trauma history: Never undergoing any operation.Infectious history:Hepatitis and TB are denied.Systemic reviewRespiratory system: No history of respiratory disease before.He has cough and chest pain for nearly 1 month. It becomes more serious at night. The patient coughs without expectorat