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1、1UnionHospitalaffiliatedtoHuazhongUniversityofScienceTechnologyAdmissionRecd0000337023Department:RespiratyMedicineArea:J17RespiratyMedicineBedNo.109031CaseNo.1565825Name:HouDeguangGender:MaleDateofBirth:1591936Age:78Nati
2、onality:ChinaIDNo.420102193609150819Ethnicity:HanOccupation:otherMaritalstatus:MarriedAddress:Nanchong，SichuanTelNo.13871426922SourceofHisty:PatientherselfReliability:ReliableAdmissionDateRespiratySystem:Chronicbronchiti
3、sfabout10yearsCirculatySystem:Hypertensionfabout20yearshighestreached18095mmHgtookAmlodipineally5mgqdBPmanagementisgood.Diagnosedofconaryheartdiseasein2007underwentintraconarystentimplantationin20083stentswereimplantedDi
4、gestiveSystems:NoneUrinarySystem:Benignprostatichyperplasiafabout5yearsDiabeticnephropathyf3yearsHematologicSystem:Thrombocytopeniaf2yearsEndocrineSystem:None.NervousSystem:Lacunarinfarctionin2011MotSystem:NoneInfectionH
5、isty:NoinfectionofhepatitisTB.Others:NonespecialPreventiveInoculation:InaccdancewiththestateplanOperationHisty:underwentintraconarystentimplantationin20083stentswasimplantatedBloodTransfusionHisty:NoneTraumaticHisty:None
6、AllergicHisty:NonePersonalHisty:HabitualResidence:HubeiResidentialEnvironment:NoexposurehistytotoxicsubstancesinfectedwaterTravellingHisty:NoneSmokingHisty:Smokingfabout40years3cigarettesperday.Quitsmokingin2008DrinkingH
7、isty:Drinkingf40years150g350gperdayQuitdrinkingin2008MaritalHisty:Married3Histysummary:1.HouDeguangmale78yr.2.Admittedf”Foundplauraleffusionfabout2months”.3.T:36.5℃.P:86bpmregular.R:20minregular.BP:13274mmHg.Expression:N
8、mal.Spiritclear.CardiacsoundsnmalHR:72bpmrhythmnmalNoabnmalextracardiacsoundscardiacmurmurs.Rightsidebreathsoundsweakenleftsidenmal.Nomoistdryralesnopleuralfrictionrubs.Flatabdomen.Norigidity.4.Specialexamination:Trachea
9、indle.Contoursymmetric.Respiratymovementregular.Rightsidebreathsoundsweakenleftsidenmal.Nomoistdryralesnopleuralfrictionrubs.5.AccessyExamination:DisgerecdofEndocrinologyDeptofourhospitalatSeptember2014Clinicexaminationa
10、tOctober13th:afewpleuraleffusionontherightsideishardtobelocalized.6.Pasthisty:RespiratySystem:Chronicbronchitisfabout10yearsCirculatySystem:Hypertensionfabout20yearshighestreached18095mmHgtookAmlodipineally5mgqdBPmanagem
11、entisgood.Diagnosedofconaryheartdiseasein2007underwentintraconarystentimplantationin20083stentswasimplantatedDigestiveSystems:NoneUrinarySystem:Benignprostatichyperplasiafabout5yearsDiabeticnephropathyf3yearsHematologicS
12、ystem:Thrombocytopeniaf2yearsEndocrineSystem:None.NervousSystem:Lacunarinfarctionin2011MotSystem:NoneInfectionHisty:NoinfectionofhepatitisTB.Others:NonespecialPreventiveInoculation:InaccdancewiththestateplanOperationHist
13、y:underwentintraconarystentimplantationin20083stentswasimplantatedBloodTransfusionHisty:NoneTraumaticHisty:NoneAllergicHisty:NoneImpression:1.Rightsidepleuraleffusioniginunknown:TBTum2.IIdiabetesmellitusDiabeticnephropat
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