一.患者，李華，男，69歲，退休教師，因心悸一年，加重5個月于1989年6月6日入院　　一年前患者健康1988年5月感到輕微心悸，在工作勞累，快走及上樓時感氣短，傍晚下肢浮腫，休息后則減輕近5個月來，心悸氣短明顯加重以致不能行走，亦不能平臥，不得不坐著度過整夜，有時咳嗽，咳少量白色粘液，無血患者無寒戰(zhàn)、發(fā)熱、胸痛或關(guān)節(jié)疼痛，排尿正?！　∠到y(tǒng)復習無特殊，1949年曾患“大葉肺炎”，無藥物過敏史個人史：生在西安，曾去過中國南方，但無疫水接觸史，抽煙一天10支，1945年結(jié)婚，其妻健康，有一女孩亦健康，其父死于胃癌，其母健在查體：體溫36.8℃，脈搏90次/分，呼吸28次/分，BP23.5/13.3kPa，發(fā)育良好，營養(yǎng)中等，體胖、半臥位，顏面蒼白，全身浮腫，神智清楚，查體合作皮膚無紅斑、黃疸、紫瘢淋巴結(jié)未觸及頭部、眼、鼻、耳、口正常，但口唇紫紺頸軟，頸靜脈無充盈，甲狀腺未觸及，無細震顫或搏動，氣管正中胸廓兩側(cè)對稱，呼吸動度對稱，無異常濁音區(qū)，但在兩肺底部可聞一些濕羅音心尖搏動所見，觸診時在第5肋間，距正中線14cm處，無細震顫，心濁音界如圖：心率90次/分，律齊，心尖部可聞Ⅱ級柔和的吹風樣收縮期雜音，P2＞A2，無胸膜磨擦音，腹軟，無壓痛及反跳痛，肝可觸及，在肋下2cm，輕度壓痛，脾未觸及；無移動性濁音，其他正常。

右（cm）?左（cm）1.5Ⅱ2.02.0Ⅲ4.03.0Ⅳ8.0　?Ⅴ14.0　?Ⅵ14.0　　正中線至左鎖骨中線距離10cm　　初步診斷：　　1.高血壓心臟病　　2.Ⅲ度心衰AN EXAMPLE OF MEDICAL CASE RECORD IN ENGLISH　　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.　　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.　　There was nothing else abnormal in the case history review except a cured lobor pneumonia in 1949. He had no history of drug allergy.　　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.　　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;Right （cm）InterspacesLeft (cm)1.5Ⅱ2.02.0Ⅲ4.03.0Ⅳ8.0Ⅴ10.0Ⅵ14.0　　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.Impression：　　disease withdegreeⅢ heart failureSignature ×××二. Medical Record of COPD Name：Liang Ya jun Occupation: driver Sex： male Date of admission: Jan ,17,2007 Age: 70 years old Date of record: Jan,17,2007 Nationality: Han Narrator of history: Himself Birth place: Beijing Level of history: reliable Chief complaint: Cough with productive of sputum for 30 years, wheeze for 10 years, and got worse for 3 days. History of present illness: 30 years ago after exposure to cold weather, the patient suffered from a cough, with purulent sputum, without fever、fatigue、night sweats、hemoptysis. With the anti-infection therapy, He was cured. Since then he was often recurrent 2-3 times every year after catching a cold or having pulmonary infection. 20 years ago, he was diagnosed the chronic bronchitis, and he had to be admitted 1-2 times 1 year for the therapy. 10 years ago, he felt shortness of breath, particularly after sports ,and 5 years ago, he began edema in his legs and feet. 3 days ago, he felt worse without any reson. He coughed all night, couldn’t lie down during sleep, sometimes with dyspnea. The sputa was sticky and purulent. But no fever. He took the oral ampicillin and aminophylline by himself ,but they didn’t work. Then he came to emergency department of TianTan Hospital. The results of blood routine was: WBC:12500/mm3, N:82.3%. The X-ray of lung: The veins of 2 pumonarys are coarse and irregular, ri。