1、1Union Hospital affiliated to Huazhong University of Science and TechnologyAdmission Record 0000337023Department: Respiratory Medicine Area: J17 Respiratory Medicine Bed No. 109031 Case No. 1565825Name: Hou Deguang Gender: Male Date of Birth: 15/9/ 1936 Age: 78 Nationality: ChinaID No. 4201021936091
2、50819 Ethnicity: Han Occupation: other Marital status: Married Address: Nanchong，Sichuan Tel No. 13871426922 Source of History: Patient herself Reliability: Reliable Admission Date Respiratory System: Chronic bronchitis for about 10 years; Circulatory System: Hypertension for about 20 years, highest
3、 reached 180/95mmHg, took Amlodipine orally 5mg qd, BP management is good. Diagnosed of coronary heart disease in 2007, underwent intracoronary stent implantation in 2008, 3 stents were implanted; Digestive Systems: None; Urinary System: Benign prostatic hyperplasia for about 5 years, Diabetic nephr
4、opathy for 3 years; Hematologic System: Thrombocytopenia for 2 years; Endocrine System: None. Nervous System: Lacunar infarction in 2011; Motor System: None; Infection History: No infection of hepatitis and TB. Others: None special; Preventive Inoculation: In accordance with the stateplan; Operation
5、 History: underwent intracoronary stent implantation in 2008, 3 stents was implantated; Blood Transfusion History: None; Traumatic History: None; Allergic History: None; Personal History: Habitual Residence: Hubei; Residential Environment: No exposure history to toxic substances and infected water;
6、Travelling History: None; Smoking History: Smoking for about 40 years, 3 cigarettes per day. Quit smoking in 2008; Drinking History: Drinking for 40 years, 150g-350g per day, Quit drinking in 2008;Marital History: Married,2Menstrual History: Male Family History: Father is deceased, mother is decease
7、d. No other infective and hereditary diseases.Physical ExaminationVital Signs: T:36.5. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Height: 164cm. Weight: 64kg. Expression: Normal. Development: Well. Nutritional status: Fairly. Consciousness: Conscious. Spirit: Well. Gait: Normal. Position
8、: Active. Coordination with Examination: Cooperative.Skin and Lymph Nodes: No jaundice. Some scattered scratch in hands and abdomen, No subcutaneous bleeding, edema, nodules or unusual pigmentation. Liver palm(-). Spider angioma(-). No swelling of general superficial lymph nodes.HEENT(Head, Eye, Ear
9、, Nose, Throat): Normal skull. No baldness, no scars. Eyes: No ptosis. Conjuctiva normal. The pupils are round, symmetric and responsive to light and accommodation is normal. Ears: Externally normal. Canals clear. Drums normal. Noses: No abnormalities noted. Month and Throat: lips red, tongue red, n
10、o swelling of tonsils.Neck: Motion free. Thyroid is not enlarged. No abnormal pulsations. Trachea in middle. Carotid: Pulse is normal. Hepatojugular reflux sign(-). Vascular bruit: None.Chest and Lung: Normal contour. Breast normal. Inspection: respiratory movement symmetric and regular. Palpation:
11、Normal and symmetric. No pleural friction fremitus. Percussion: both sides resonance. Auscultation: right-side breath sounds weaken, left-side is normal. No moist or dry rales. No pleural friction rubs.Heart: No protrusion of precordium. Normal apical impulse. No thrill. No enlarged cardiac dullness
12、 border. Heart rate: 88bpm, rhythm normal. No abnormal and extra cardiac sounds or cardiac murmurs. No peripheral vascular signs.Abdomen: Flat abdomen. No gastric or intestinal pattern. No visible peristalsis. Normal bowel sound. No rigidity. No mass palpable. No tenderness and rebound tenderness. L
13、iver and spleen are not palpable. Kidneys are not palpable. No percussion tenderness over kidney regions. No shifting dullness.Rectum: Normal anus and perineum.Genitourinary System: Normal.Neural System: Normal.Extremities: No joint disease. Muscle strength normal. Pathological reflex (-).Specialty
14、Examination: Right-side breath sounds weaken, left side normal. No moist or dry rales, No swelling of general superficial lymph nodes. No edema in neither lower extremities.Accessory Examination: Discharge record of Endocrinology Dept. of our hospital at September 2014; Clinic examination at October
15、 13th: a few pleural effusion on the right side and is hard to be localized.3History summary: 1. Hou Deguang, male, 78 yr.2. Admitted for ”Found plaural effusion for about 2 months”.3. T:36.5. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Expression: Normal. Spirit clear. Cardiac sounds nor
16、mal, HR: 72 bpm, rhythm normal, No abnormal and extra cardiac sounds or cardiac murmurs. Right-side breath sounds weaken, left side normal. No moist or dry rales, no pleural friction rubs. Flat abdomen. No rigidity. 4. Special examination: Trachea in middle. Contour symmetric. Respiratory movement r
17、egular. Right-side breath sounds weaken, left side normal. No moist or dry rales, no pleural friction rubs.5. Accessory Examination: Discharge record of Endocrinology Dept of our hospital at September 2014; Clinic examination at October 13th: a few pleural effusion on the right side and is hard to b
18、e localized. 6. Past history: Respiratory System: Chronic bronchitis for about 10 years; Circulatory System: Hypertension for about 20 years, highest reached 180/95mmHg, took Amlodipine orally 5mg qd, BP management is good. Diagnosed of coronary heart disease in 2007, underwent intracoronary stent i
19、mplantation in 2008, 3 stents was implantated; Digestive Systems: None; Urinary System: Benign prostatic hyperplasia for about 5 years, Diabetic nephropathy for 3 years; Hematologic System: Thrombocytopenia for 2 years; Endocrine System: None. Nervous System: Lacunar infarction in 2011; Motor System
20、: None; Infection History: No infection of hepatitis and TB. Others: None special; Preventive Inoculation: In accordance with the stateplan; Operation History: underwent intracoronary stent implantation in 2008, 3 stents was implantated; Blood Transfusion History: None; Traumatic History: None; Alle
21、rgic History: None; Impression: 1. Right-side pleural effusion origin unknown: TB? Tumor?2. II diabetes mellitus, Diabetic nephropathy3. Hypertension III, high risk4. Coronary heart disease, post-intracoronary stent implantation5. Lacunar infarction6. Thrombocytopenia7. Benign prostatic hyperplasiaRecorder: Cheng LongDate & Time: 4/11/2014 16:14Checker: Xu JuanjuanDate & Time: 5/11/2014 10:22
