Cough and dyspnea for several days.
According to the patient`s statement of himself, he had a history of bronchial as-
thma for 20 years. One month ago, he was told he had a history of Pul TB. He
took anti-TB drug for one month. This time’ he had suffered cough and dyspnea
for several days. He was sent to a local clinic and was then teansferred to our hos-
pital for further evaluation and management. Throughout the whole course of
the present illness there was no fever or chills, and on cyanosis sign. Tachycardia
and nausea were noted. This time he was admitter from OPD to medical ward.
Past, Personal and Family History:
1.He had a history of Bronchial asthma for 20 years.
2.He had a history of taking herbal medicine with steroids for 20 years.
3.He had a history of NIDDM.
4.He had a history of pul TB.
General Appearance: acutely ill-looking. Development:MD
Mentality: alert Skin:ecchymosis on extremities
Head and its Organs: intact
Conjunctiva: No anemic Sclera: No icteric
Neck:soft Lymph Nodes: not palpable
Chest:symmetrical and full expansion.
Heart:Tachycardia with regular heart beat. No murmur.
Lungs:wheezing sound in both lungs
Abdomen: Soft and flat. No tenderness or rebounding pain.
Liver: not palpable
Spleen: not palpable
Extremities: no edema
Reflexes: no pathological reflex
Others: BP: 120/80mmHg
Lmpression: Bronchial asthma
- 1 0 年前最佳解答
根據病人的自述他有支氣管性氣喘的病史長達20年.一個月前,他被告知有肺結核的情形 並且開始服用抗結核病藥物.這一次,他覺得咳嗽及呼吸困難長達一段時間.他去過診所求治,並且為了進一步的治療,他被轉診至我們醫院.經過全面的評估,他沒有發燒或寒顫 跟發酣的情形.心搏過速跟惡心感確是存在的.這次他由門診辦理入院至內科病房.