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1、一.患者，李华，男，69岁，退休教师，因心悸一年，加重5个月于1989年6月6日入院。一年前患者健康。1988年5月感到轻微心悸，在工作劳累，快走及上楼时感气短，傍晚下肢浮肿，休息后则减轻。近5个月来，心悸气短明显加重。以致不能行走，亦不能平卧，不得不坐着度过整夜，有时咳嗽，咳少量白色粘液，无血。患者无寒战、发热、胸痛或关节疼痛，排尿正常。系统复习无特殊，1949年曾患“大叶肺炎”，无药物过敏史。个人史：生在西安，曾去过中国南方，但无疫水接触史，抽烟一天10支，1945年结婚，其妻健康，有一女孩亦健康，其父死于胃癌，其母健在。查体：体温36.8，脉搏90次/分，呼吸28次/分，BP23.5/1
2、3.3kPa，发育良好，营养中等，体胖、半卧位，颜面苍白，全身浮肿，神智清楚，查体合作。皮肤无红斑、黄疸、紫瘢。淋巴结未触及。头部、眼、鼻、耳、口正常，但口唇紫绀。颈软，颈静脉无充盈，甲状腺未触及，无细震颤或搏动，气管正中。胸廓两侧对称，呼吸动度对称，无异常浊音区，但在两肺底部可闻一些湿罗音心尖搏动所见，触诊时在第5肋间，距正中线14cm处，无细震颤，心浊音界如图：心率90次/分，律齐，心尖部可闻级柔和的吹风样收缩期杂音，P2A2，无胸膜磨擦音，腹软，无压痛及反跳痛，肝可触及，在肋下2cm，轻度压痛，脾未触及；无移动性浊音，其他正常。右（cm）左（cm）1.52.02.04.03.08.014
3、.014.0正中线至左锁骨中线距离10cm初步诊断：1.高血压心脏病2.度心衰AN EXAMPLE OF MEDICAL CASE RECORD IN ENGLISHPatient Li Hua,mate,69 years old, a retired teacher, was admitted on June 6,1989,because of palpitation for one year and becoming worse in recent 5 months.The patient was quite well until one year before May,1988, He
4、felt slight palpitation and dyspnia during hard work, fast walk , or climbing stairs, There was swelling of legs in the evening but he felt better after having a rest. In recent 5months, palpitation and dyspnia became so serious that he could neither walk nor lie down.He had to sit up during the who
5、le night, Sometimes he coughed with small amounts of sputum, but without blood. He had no chill, fever, chest pain or sore joints. The urinating was normal.There was nothing else abnormal in the case history review except a cured lobor pneumonia in 1949. He had no history of drug allergy.Personal hi
6、story：The patient was born in Xian in 1923. He had been to the south of China but did not contact contaminated water. He smoked a bout 10 cigarettes daily. He got married in 1945. His wife was healthy .They had a daughter who was also healthy. His father died of stomach cancer.His mather was well.Ph
7、ysical Examination：T.36.8C, P. 96/min, R. 28/min, BP.23.5/13.3kPa. The patient, an old fatty man who developed well and moderately nourished, was lying in bed with a semifallous position. He looked pale and suffered from general edima. He was mentally normal and cooperative in the examination.There
8、was no eruption, no jaundice, no purpura on the skin, and the lymphnodes were not palpable. The head, eyes, nose, ears, mouth were normal while the lips were cyanotic. The neck was soft, there was no venous engorgement. Thyroid glands were not palpable, there were no thrill or brunt. The trachea was
9、 in midline. The chest and respiratory movements were symmetrical. There was no abnormal dullness but some moist rales were heard in the base areas of the both lungs. The points of maximal impulse (PMI) were not visible but palpable in the 6thcostal interspace, 14cm form the middle line, there was n
10、o thrill. The cardiac dullness, 14cm from the middle line, there was no thrill. The cardiac dullness were as follows;Right （cm）InterspacesLeft (cm)1.52.02.04.03.08.010.014.0The distance from midsternal line to midclavicular line was 10cm. The heart rate was 96/min, regular. There was a grade soft bl
11、owinglike systolic murmurat the apex,P2A2, but no pericardium friction sound was heard. Abdominal wall was soft without tenderness. The liver was palpable 2cm below the costal margin with slight tenderness. The spleen was not palpable and there was no shifting dull ness. The rest was normal.Impressi
12、on：disease withdegree heart failureSignature 二. Medical Record of COPD Name：Liang Ya jun Occupation: driver Sex： male Date of admission: Jan ,17,2007 Age: 70 years old Date of record: Jan,17,2007 Nationality: Han Narrator of history: Himself Birth place: Beijing Level of history: reliable Chief comp
13、laint: Cough with productive of sputum for 30 years, wheeze for 10 years, and got worse for 3 days. History of present illness: 30 years ago after exposure to cold weather, the patient suffered from a cough, with purulent sputum, without fever、fatigue、night sweats、hemoptysis. With the anti-infection
14、 therapy, He was cured. Since then he was often recurrent 2-3 times every year after catching a cold or having pulmonary infection. 20 years ago, he was diagnosed the chronic bronchitis, and he had to be admitted 1-2 times 1 year for the therapy. 10 years ago, he felt shortness of breath, particular
15、ly after sports ,and 5 years ago, he began edema in his legs and feet. 3 days ago, he felt worse without any reson. He coughed all night, couldnt lie down during sleep, sometimes with dyspnea. The sputa was sticky and purulent. But no fever. He took the oral ampicillin and aminophylline by himself ,but they didnt work. Then he came to emergency department of TianTan Hospital. The results of blood routine was: WBC:12500/mm3, N:82.3%. The X-ray of lung: The veins of 2 pumonarys are coarse and irregular, ri
