The hospital records

Name: Ma Zhengkui Gender: Male

Date of Birth: June 2, 1965 Place of birth: Xiaoshan City, Zhejiang Province
Occupation: Other Nationality: Han
Marital Status: Married Address: Town, Xiaoshan District guali new village
Admission time: 2015-03-17 09:37
history presenter: I write, MD: Wu Shengjun (attending)
Chief Complaint: Physical examination revealed a half months left coronary artery
aneurysms
History of present illness: Patients half months ago because of a finger injury in the Fourth
People's Hospital of Xiaoshan prompt abnormal chest X-ray (specifically unknown), when
the mood before pain, chest tightness after no activity, no palpitations, dizziness, chills, no
fever, no cough, sputum and other discomfort and went to the First People's Hospital of
Xiaoshan treatment, check show enhanced chest CT (2015-03-09): left lung slug shadow,
the sources of the left coronary artery aneurysm? Recommend surgery.
Currently patients without chest pain and discomfort, for the sake of further surgery in our
hospital, clinic intends "coronary artery aneurysms," admitted to hospital.
Shen Qing sick patients, can the spirit, appetite can sleep can, no two will be special, no
significant changes in body weight.
Both to history: The patient in the past a good physique. See history of heart disease is now
history; by the state vaccination; a history of trauma to the left index finger a half months ago
trauma, conservative treatment. No history of hypertension, diabetes, kidney disease history;
no history of tuberculosis, viral hepatitis history, history of other infectious diseases; denied
food allergy medication; no surgery; no history of blood transfusion; no history of poisoning;
no long-term medication history; no possibility to drug addiction.
Personal history: the birth and growth of long-term residence in Xiaoshan, steelworkers,
junior high school education. No epidemic residence history. No Excursion history. There are
more than 20 years drinking habits, daily two two liquor, did not quit. No smoking habits.
Non-toxic and radioactive substances contact history. Marital harmony.
Obstetrical history: The patient was 27 years of marriage, the spouse's health. Father of 2
girls, both body and health.
Family history: family, no similar patients. Father suffering from hypertension. Mother
suffering from hypertension. Siblings Health: a brother, a sister, a sister, both body and
health. No immediate family illness similar items. The patient denied a genetic history of
three generations of two lines. Patients with a genetic predisposition to the disease denied.
Physical examination:
Vital signs: temperature: 37 pulse: 76 beats / min breathing: 20 beats / min BP: 152 /
88mmHg
General: development: no deformity Nutrition: Good mind: clear breathing: uniform face:
Normal
Wink: Normal position: independent posture gait: smooth with check: with
Skin: pale: no flushing: None cheeks flushing: no cyanosis red: None yellow: None
Rash: None purpura: None

Edema: No dehydration: None tightness: moderate

Temperature: Moderate sweating: No overt sweating scar: no infection: None
Head: Size: Normal malformations: no mass: None
Depression: no tenderness: None
Eye: eyelid: conjunctival edema: no congestion sclera: without jaundice
Four quadrants of the eye movement: left: Normal eye: normal
Eye appearance: left: Normal eye: normal cornea: no turbidity pupil: other large and round
Light reflex: left: the keen eye: sensitive
Nose: Shape: Normal other anomalies: no paranasal sinus tenderness: None
Mouth: lips: no cyanosis mucosa: no congestion parotid duct openings: Normal
Tongue: Shenshe center gums: no swelling caries: None
Throat: tonsil: Normal pharynx: no congestion sound: normal
Lymphatic: lymph nodes: the body of superficial lymph nodes no time
Neck: Resistance sense: no carotid artery: normal jugular vein pulsatility: no engorgement
Trachea: middle jugular vein reflux symptoms: None
Thyroid: enlargement
Chest: thorax: no deformity of the breast: Adult male breast
Lungs: visual examination: breathing exercises: Xiongshihuxi exist
Palpation: fremitus: symmetrical pleural friction sensitivity: None
Percussion: percussion sounds: the lower bound of normal lung activity voiceless: 6cm
Auscultation: Respiratory: smooth lung breath sounds: Clear
Voice conduction: normal pleural friction rub: None
Heart: visual examination: diffuse apex beat: No other position: Normal
Palpation: apex beat Location: Normal apex beat: normal vibrations: unintentional package
friction sensitivity: None
Percussion: cardiac dullness is located in the fifth intercostal space left subclavian midline
0.5cm
The relative dullness of heart ---------- -----------------------------------Right (cm) ---------- ---------- left intercostal (cm)
Chest ---------- ---------- 2.0
Bone ---------- ---------- 3.0
Right ---------- ---------- 5.0
Edge ---------- ---------- 7.0
(Left subclavian central line from the center front 7.5cm)
Auscultation: Heart rate: 76 beats / min heart rate: united voice: no smell and abnormal heart
sounds
Extra heart sounds: no noise: unintentional package fricative: None
Peripheral vascular: abnormal vascular sign: None
Abdomen: visual examination: Shape: flat abdominal breathing: the presence of umbilical:
No highlight
Other anomalies: None
Palpation: abdominal tension: soft tenderness: None

Rebound: None
Fluid wave tremor: no sound vibration of water: None
Abdominal mass: None
Liver: ribs no
Gallbladder: untouched Murphy sign: negative
Spleen: untouched
Percussion: hepatic dullness: normal shifting dullness: None
Kidney area percussion pain: None
Auscultation: bowel sounds: no hyperactive bowel sounds diminished Frequency: 3 times /
min
Air over the water sounds: no bruit: None
Anorectal: not detected
Genital: not detected
Spine extremities: spine: no deformity of limbs: normal activity: to
Tenderness, percussion pain: None
Clubbing of the fingers and toes: None
Nervous System: abdominal reflex: normal limb paralysis: None
Muscle tone: normal muscle strength: V Class
Biceps reflex: Normal Hoffman sign: negative
Knee tendon reflexes: Normal Kernig sign: negative
Achilles tendon reflex: normal Babinski sign: negative
Other: See specialist examination
Supplement and specialist case
Shen Qing, the spirit can, lips no cyanosis, no time superficial lymph nodes, lung breath
sounds clear, no smell and wet rales, heart rate 76 beats / min, the law Qi, the valve area is
not known and obvious pathological murmurs, rubs mood package and less tremor,
abdomen soft, no tenderness, liver and spleen ribs, shifting dullness negative, lower
extremity edema, neurological negative.

Auxiliary examination:
Special examination: chest CT shows enhancement (2015-03-09 First People's Hospital of
Xiaoshan City): left lung slug shadow (about the size of 58 * 51mm), the source of the left
coronary artery aneurysm? Recommend DSA.

Nutritional screening results: negative, no nutritional consultation.

Rehabilitation screening results: negative, no rehabilitation consultation.
Initial diagnosis: coronary artery aneurysm (left coronary artery)

Coronary artery aneurysms (left coronary artery)

Physician Signature: Wu Shengjun (attending)

Date: 2015-03-17 10:40