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1、MedicalRecordofCOPDName：LiangYajunOccupation:driverSex：maleDateofadmission:Jan,17,2011Age:70yearsoldDateofrecord:Jan,17,2011Nationality:HanNarratorofhistory:HimselfBirthplace:BeijingLevelofhistory:reliableChiefcomplaint:Coughwithproductiveofsputumfor30years,wheezefor1
2、0years,andgotworsefor3days.Historyofpresentillness:30yearsagoafterexposuretocoldweather,thepatientsufferedfromacough,withpurulentsputum,withoutfever、fatigue、nightsweats、hemoptysis.Withtheanti-infectiontherapy,Hewascured.Sincethenhewasoftenrecurrent2-3timeseveryyearaft
3、ercatchingacoldorhavingpulmonaryinfection.20yearsago,hewasdiagnosedthechronicbronchitis,andhehadtobeadmitted1-2times1yearforthetherapy.10yearsago,hefeltshortnessofbreath,particularlyaftersports,and5yearsago,hebeganedemainhislegsandfeet.3daysago,hefeltworsewithoutanyre
4、son.Hecoughedallnight,couldn’tliedownduringsleep,sometimeswithdyspnea.Thesputawasstickyandpurulent.Butnofever.Hetooktheoralampicillinandaminophyllinebyhimself,buttheydidn’twork.ThenhecametoemergencydepartmentofTianTanHospital.Theresultsofbloodroutinewas:WBC:12500/mm3,
5、N:82.3%.TheX-rayoflung:Theveinsof2pumonarysarecoarseandirregular,right-lowerpulmonaryarterialtrunk>15mmHg,cardiacapexbeingglobularappearanceandmoreelevatedandemphysema.Hewasgivensomedrugsofanti-infection,buttheeffectisnotgood.Tobewelltreated,hewasinchargedofacuteepiso
6、deofCOPD.Thesedays,hefeltweakness,poorofappetite,theurineandstoolarenormal,hisweightdidnotchange.Pasthistory:HehashadHypertensionfor30years,DMfor4-5years.1986:myocardialinfarction,fullrecovery/Nosubsequentinvestigation.SocialHistory:Smokingfor50years,theamountisabouth
7、alfacigarettecaseperday.Neverdrink.BornandlivesinBeijing,Neverbeentoareaofpestilence.Marriedfor45yearswith2childrenandbothofthemarehealthy.Familyhistory:Nofamilyhistoryofchronicdiseaseandgeneticdisease.ReviewofSystemsRespiratorysystem:Sameasthehistoryofpresentillness.
8、Gastrointestinaltract:Nocurrentindigestion.Novomiting/dysphagia/diarrhea/constipation/abdominalpain.Cardiovascularsystem:Noc
