Medical Records for Admission
Medical Number: 701725
住院病历
病历号： 701725
Patient 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.
患者，李华，男，69岁，退休教师，因心悸一年，近5个月加重，于1989年6月6日入院
The patient was quite well until one year before May,1988, He 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 whole 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.
患者一年来健康。1988年5月感到轻微心悸，在工作劳累、快走及上楼时感到气短，傍晚下肢浮肿，休息后减轻。近5个月来，心悸气短明显加重，以致不能行走和平卧，不得不整夜坐着。有时咳嗽，伴少量粘痰，无咳血。患者无寒战、发热、胸痛或关节疼痛，排尿正常。
There was nothing else abnormal in the case history review except a cured lobor pneumonia in 1949. He had no history of drug allergy.
除1949年曾患“大叶肺炎”，询问病史其他无特殊，无药物过敏史。
Personal history：The patient was born in Xi’an 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.
个人史：1923年出生于西安，曾去过华南，但无疫水接触史。抽烟一天10支。1945年结婚，其妻健康，有一女儿亦健康。其父死于胃癌，其母健在。
Physical 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 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 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 no thrill. The cardiac dullness, 14cm from the middle line, there was no thrill. The cardiac dullness were as follows;
查体：体温36.8℃，脉搏90次/分，呼吸28次/分，血压23.5/13.3kPa。发育良好，营养中等，体胖。患者半卧位，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，无震颤或搏动。气管居中，胸廓及呼吸动度对称，无异常浊音区，但两肺底部可闻一些湿罗音。心尖搏动未见，触诊时在第６肋间，距中线14cm处，无震颤，心浊音界如下：
Right （cm） Interspaces Left (cm)
1.5 Ⅱ 2.0
2.0 Ⅲ 4.0
3.0 Ⅳ 8.0
Ⅴ 10.0
Ⅵ 14.0
The distance from midsternal line to midclavicular line was 10cm. The heart rate was 96/min, regular. There was a grade Ⅱsoft blowinglike systolic murmurat the apex,P2>A2, 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.
正中线至锁骨中线距离10cm，心率90次/分，律齐，心尖部可闻Ⅱ级柔和的吹风样收缩期杂音，P2＞A2，无胸膜磨擦音，腹软，无压痛。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。
Impression：
Hypertension heart disease with degreeⅢ heart failure
印象：高血压心脏病
伴Ⅲ度心衰
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