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1、CompleteHistory Name:SiRuihua Department:Lumber electricpowerbureauSex:female Presentaddress:electricpowerbureauAge:80years Dateofadmission:2003-5-17Nationality:Chinaxinjiang Dateofrecord:2003-5-17Maritalstatus:bemarried
2、 Reliability:reliableOccupation:familynumbers Historyofallergy:denyChiefcomplaints: Palpitationandbreathlessnssfor1hourPresentillness: Thepatientcomplainedofpalpitationwithnoprecipitatingfactorsanhourago,atthesametimeshestillfeelbreahlessnessandprecardialpainwhichdidn’tradiatedtoother
3、partsofbody.Thisdiscomfortcan’tberelievedbytakearest.Ascouldn’tsufferfromthatshehadtocametohospitalforhelp.Inthecourseofthe illness,hehadnosyncope,nocough,noheadache,nodiarrheaandvomiting.Herappetite,sleep,voidingandstoolwerenormal.Pasthistory: Thepatientdenythehypertension,diabetesmellitus,obe
4、sityandvalvularheartdiseasehistory.denytheallegiestopollen,dustmedicationsorfood.Denythesurgicalproceduresandinjuries.Reviewofsystems:Respiratorysystem: nopharyngalgia;nochromiccoughorhemoptysis;nodyspneaandthoracalgia;noafternoonfeverornightsweats.Circulatorysystem: nopalpitationandbreathless
5、nessonexertion:noprecordialpain,dizzinessandpersistentheadache;nosyncopeandhypertension.Digestivesystem: nosourregurgitationanddysphagia:nochronicabdominalache,diarrheaandvomiting:nojaundice,hematemesisandmelena.Urinarysystem: nopasthistoryofedemaandproteinuria;nopollakiuria;nourgencyandpainfu
6、lmicturition;novisiblehematuriaandhypertension.Endocrineandmetabolicsystem: noirritability,hidrosisorprofoundfatigueandheadache;noimpairedvision,exceedingthirstyandpolyuria;noexcessivehairinessorhairloss;nopigmentationandsexualitychange.Hematopoieticsystem: nopaleshin,nodizziness,blurredvision
7、andtinnitus;noimpairmentofmemory;nopetechiaandjaundicovertheskinandmucosa;nolymphnode,liverandspleenenlargement;noabnormalbonypain.Muscle,boneandjointsystem: nounusualpain,rednessandswellingofthejoints;nodeformityofjoints;n
