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一九八六年二月十五日查房记要主治医师:请实习医师甲报告病历。实习医师甲:男患,58岁,因咳嗽,阵发性呼吸困难,咯血,劳累后心前区闷痛于八六年一月二十九日入院。患者于15年前即有长期慢性咳嗽病史,每逢秋冬季节常因着凉感冒而病情加重。4年前始有心悸、气短、下肢浮肿,经抗炎、利尿、服用氨茶硷可缓解。近半年来常因劳累或情绪激动后,自觉气短,
February 15, 1986 Check-in Note To the attending physician: Please report to the intern a. Intern a: male suffering, 58 years old, due to cough, paroxysmal dyspnea, hemoptysis, fatigue after heart area boring pain on January 29, 1986 admission. The patient had a long history of chronic cough 15 years ago, often exacerbated by a cold and a cold every autumn or winter. 4 years ago palpitations, shortness of breath, lower extremity edema, anti-inflammatory, diuretic, taking aminophylline can be alleviated. Nearly six months often due to fatigue or emotional excitement, shortness of breath,