英文完全病例书写(呼吸科).docVIP

Medical Record of Admission Name: Guo XX Sex: Male Age: 41 years old Marital status: Married Race: Han Occupation: Worker Place of birth: Chenzhou City, Hunan province Address: Linwu County, Chenzhou City, Hunan province Date of admission: 11：12 AM, 05,12,2014 Date of records: 17:20PM, 05,12,2014 Complainer: Guo XX Chief complaint: Cough for two months, and tachypnea and chest pain for one month. History of present illness: The patient have no obvious cause cough in October this year, a small amount of white sticky sputum, blood in the sputum, no chest pain, no fever, occasionally night sweats, it has no special treatment. November 10th, the patients with fever, the highest temperature of 39.2 degrees, tachypnea, chest pain, hence clinic in Linwu county people's hospital, the number of WBC has been checked a little bit high, chest CT shows on the left side of the massive pleural effusion, a little right lung infection, diagnosis left pleural effusion, pleurisy to fight infection (specific drug use is unknown), no significant improvement in symptoms. Then transferred to the first people's hospital of Chenzhou, also the number of WBC has been checked a little bit high, calcitonin original high, c - reactive protein and blood sedimentation increase fast, pleural effusion as exudates, diagnosed as check the left pleural effusion due to: tuberculosis likely, double lung infection, to the amp south + levofloxacin anti-infection, fever back slightly, but still has a low thermal afternoon, in the 2014-11-20 to diagnostic anti-tuberculosis (quadruple the chemotherapy plan: isoniazid 0.3 qd + rifampicin 0.45 g qd + pyrazinamide 0.5 tid + ethambutol 0.75 qd), patient with no fever, cough, chest pain, were compared with the previous improved patient for diagnosis hence to our hospital. Since the onset of the patient with a good spirit, appetite, sleep, and fever