病历英文摘要(1)summary70-year-oldmalesmokerwithafamilyhistoryandprevioushistoryofchronicbronchitis,presentswith20-yearhistoryofcough,sputum,wheezeandgotworsefor3-day,whichisunrelievedbyampicillinandaminophylline.Onexamination,therearemoistanddryralesinbothlungs.Bloodrouti...
(1)summary70-year-oldmalesmokerwithafamilyhistoryandprevioushistoryofchronicbronchitis,presentswith20-yearhistoryofcough,sputum,wheezeandgotworsefor3-day,whichisunrelievedbyampicillinandaminophylline.Onexamination,therearemoistanddryralesinbothlungs.Bloodrouting:WBC12500/mm3,N82.2%.X-RAY:right-lowerpulmonaryarterialtrunk>15mmHg,cardiacapexbeingglobularappearanceandmoreelevatedandemphysema.ThemostlikelydiagnosisisanacuteepisodeofCOPD(chronicobstructivepulmonarydisease).(2)summary47-year-oldmalesmokerwithafamilyhistoryandprevioushistoryofischaemicheartdisease,presentswiths4-monthhistoryofincreasingexertionalchestpainanda4-hourhistoryofpersistent,severepainatrest,whichisunrelievedbyGTNandassociatedwithnausea,vomiting,andsweating.Onexamination,hehasarestingtachycardiaandevidenceofleftventriculardilatationwithadisplacedapexbeatandpossiblesecondarymitralregurgitation.Themostlikelydiagnosisisacutemyocardialinfarction.(3)Summary1.Patientwasmale80yearsold2.Upperbellyachetendayshaematemesishemafeciaandunconsciousnessforfourhours.3.Nospecialpasthistory.4.Physicalexamination:T37.5℃P130/minR23/minBP100/60mmHgSuperficiallymphnodeswerenotfoundenlarged.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.Nootherpositivesigns.5.investigationinformation:Blood-Rt:Hb69g/LRBC2.80T/LWBC1.1G/LPLT120G/LImpression:uppergastrointestinehemorrhage
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