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1、MedicalRecordsforAdmissonGeneralinformationName:ZHOUXubaoAge:79Sex:MaleRace:HanNationality:ChinaAddress:Occupation:RetiredMaritalstatus:MarriedDateofadmission:Jun9th,2014Dateofrecord:Jun12th,2014Complainerofhistory:patienthimselfReliability:ReliableChiefcomplaint:Coughandchestpainfornear
2、ly1month,withweakness.Presentillness:Thepatientbegantocoughandfeelchestpainnearly1monthago.Itbecomesmoreseriousatnight,sometimes,thepatientiswakenedwithcough.Thepatientcoughswithoutexpectorationandhemoptysis.Hedoesn’thavefever,either.Thechestpainworsenedgradually.Atfirst,itwasneedle-like
3、painontherightlateralthoracicwall,anditdevelopedtodoublesidepainaroundtheareaofinferiorboundaryoflung5or6daysago.Thepainisassociatedwithposition,anditworsenedwithmovement.OnthemorningofJun9th,2014,thepatientwenttolocalhospital,theX-rayexaminationindicatedmoderateamountofrightpleuraleffus
4、ion.Thepatientcametoourhospitalintheafternoon.OnJun9th,2014,thepatientwastreatedwithchestdrainageofabout750ml(1.5bags)bloodypleuralfluid.NostructuralalternationswereseeninechoandECG.Sincethediseasecomingon,thepatient’sspirit,sleepwasnormal.Appetitedecreased.Stoolandurinewerenormal,too.Pa
5、sthistory30-40yearsago,thepatienthadgastrorrhagiafor3times,cured.20-30yearsago,thepatienthadcoronaryartery’sdisease,cured.Thepatienthasgoatfor3-4years.Thepatienthashypertensionfor2-3years,andtakesnifedipineregularly.Historyoftransfusion:Denied.Allergichistory:Allegichistoryoffoodanddrugs
6、isdenied.Operationandtraumahistory:Neverundergoinganyoperation.Infectioushistory:HepatitisandTBaredenied.SystemicreviewRespiratorysystem:Nohistoryofrespiratorydiseasebefore.Hehascoughandchestpainfornearly1month.Itbecomesmoreseriousatnight.Thepatientcoughswithoutexpectorationandhemoptysis
7、.Hedoesn’thavefeverCirculatorysystem:Thepatienthadcoronaryartery’sdisease20-30yearsagoandcured.Thepatienthashypertensionfor2-3yearsandtakesnifedipineregularly.Degisticesystem:Nohistoryoflowappetite,sourregurgitation,belching,nausea,vomiting,abdominaldistension,abdominalpa
