英文病历englishi case (ami).doc

1 Medical Records for Admission Complete History Medical Number: 136049 General information ： Name：*** Occupation ：Intendant Sex：Male Educational level：Undergraduate Age：46 Date of Admission ：16Pm, Nov 15,2012 Nationality：Han Date of Record：17:30Pm, Nov 15, 2001 Nativity：GuangXi Informant ：Patient himself and his wife Marital Status ：Married Reliability：Reliable Department of work：Xinjiang Construction Engineering Group Corporation Address：Room201,Unit4,11th Building,Taixiu Residential, Altay Road Chief Complaints ：Repeated chest pain four days, aggravation for half an hour. Present Illness ：The patient had felt precordial pain after drinking 4 days ago, accompanying by upper limbs soreness, fatigue, for 30 minutes to ease. Afterwards, in symptoms after drinking relapse, did not undergo treatment. Around 14:00 today, the patient felt chest pain again when driving, and the symptoms significantly worse than before, accompanying chest tightness, breathlessness, profuse sweating, soreness and weakness of the upper limbs, and feeling of impending death. For the symptoms continued for half an hour had not alleviated, the patient visited the emergency department. There was ST segment elevation across the precordial leads(V1-V6), and in leadsⅠand avL on the surface ECG at that time. Received emergent treatment, the patient sudden lost of consciousness at 14:50, and ventricular fibrillation was observated on cardiac monitor. Given electric defibrillation , the patient was recovery of consciousness, but ventricular fibrillation occurred again and again. After received 13 times electric defibrillation, the patient maintains stable vital signs, and transferred to the coronary care unit. Past History：The patient has suffered from the 8-year history of “hypertension”, with the most blood pressure of 170/120mmHg, and 1- year history of “gout”. He denied any history of infectious diseases including “hepatitis”， “tuberculosis” and “typhoid fever” etc． There was no related history of operation and trauma ．He had a history of 2 allergy to Sulfanilamide ． Review of Systems ： Respiratory System：No pharyngalgia；no chronic cough or haemoptysis；no thoracalgia；no afternoon fever or night sweats ． Circulatory System：No breathlessness on exertion；no dizziness and persistent headache ；no syncope and amaurosis ． Digestive System ：No sour regurgitation and dysphagia；no chronic abdominal ache ，diarrhea and vomiting ；no jaundice，hematemesis and melena． Urinary System：No past history of edema and proteinuria；no pollakiuria；no urgency and painful micturition；no visible hematuria ． Endocrine and Metabolic System：No irritability，hidrosis or profound fatigue and headache；no impaired vision，exceeding thirsty and polyuria；no excessive hairiness or hair loss；no pigmentation and sexuality change． Hematopoietic System：No pale skin ，no dizziness ，blurred vision and tinnitus；no impairment of memory；no petechia and jaundic over the skin and mucosa ；no lymph node，liver and spleen enlargement；no abnormal bony pain． Muscle，bone and Joint System：No unusual pain ，redness and swelling of the joints； no deformity of joints ；no limbs and trunk limitation on motion；no myoasthenia and myoatrophy． Nervous System ：No persistent headache and syncope；no memorial impairment or speaking obstacle ；no insomnia and consciousness obstacle ；no paresthesia of skin；no paralysis and convulsion ．Mental Status ：No hallucination ，delirium and orientation obstacle ；no abnormal emotion ． Personal History：The patient was born in Xingjiang．He has smoked an average of 40 cigarettes daily for 30 years. Patients has a history of drinking more than 10 years, daily alcohol consumption of 50- 250ml. Marital History：She married for 26 years．His wife and son is in good health with happy family life． Family History：The patient’s father died from cancer. His mother is suffering “hypertension, coronary heart disease and diabetes ”. His brother is suffering “coronary heart disease”.There was no history of other familial hereditary diseases.3 Physical Examination T：36.4 ℃ P：98/min R：18/min BP ：109/74mmHg W：unmeasured General condition：Normally developed，moderately nourished；active position，alert and cooperative． Skin and Mucosa：Normal temperature ； no jaundice，eruptions or bleeding spots； no pigmentation ，mile to moderate edema of bilateral eyelids and lower extremilies． Lymph glands：No superficial lymph nodes enlargement． Head organ ：Normal shape of head；hair black and shining with average distribution ； no scars． Eyes：Mild edema of eyelids ；no bleeding spots of conjunctivano sclerae jaundice；cornea clear ，pupils round，symmetrical in size and acutely reactive to light ． Ears：Normal hearing；no purulent secretion of the external canals ；no tenderness over mastoids ． Nose：No obstruction ；no deviation of septum ；no discharge or tendern。