Here is a diagnosis record, please help me with my treatment
My friend, an old man had a visit to his local hospital and been given a diagnosis. I post here had ask somebody can give some advice on his medicine treatment. Thanks !
Look forward your advice.
Name: my friend Occupation: Worker
Sex: Male Age: 65 years old
Marriage: Married History Supply: Patient self, reliable
Birthplace: Shanghai Race: Han
Work for: Jian Hu Country Hong Da Pipe Fitting Co., Ltd
Address: The Family Dormitory Area of Jian Hu Country Hong Da Pipe Fitting Co., Ltd
Date of Admission: 9, Nov, 2010 Time: 12:10 A.M
Date of Record: 10, Nov, 2010 Time: 09:10 A.M
In the past two years, the patient had felt oppression in chest, asthma(dyspnea) and palpitation on exertion(in movement), it became serious in recent three days and accompanied with cough.
Current History of Illness:
The patient, male 65 years old, had hypertensive medical history in past.
He took some antihypertensive medicine, but which was not clear. He also used insulin glargine as medical treatment for DM and we didn't get the real adopting quantity . We know about the patient had undergone an intracoronary stent implantation in a hospital when he was in USA one month before, however, the concrete situation about the operation was also not clear.
The patient had no history of drug allergy. Two years ago, the patient initially self felt oppression in chest, asthma and palpitation in movement. He felt better after having a rest. The symptom, to which was not paid attention at the beginning, aggravated gradually in the following days.
In another hospital visiting, the patient was used to be examined with ECG(electrocardiogram), echocardiologe, etc. As result, he was diagnosed as “Coronary heart disease”. The symptom had become better for medical treatment, thereafter, it attacked many times along with irregular treatment. The patient whose lower limp have no obvious swelling can complete his own daily life when he was not within stage of attack. The patient coughed and discharged yellow viscous sputum with catching a cold three days before, the palpitation and oppression in chest aggravated accompany with asthma and dyspnea. The situation was so serious that he could not lie down during the night.
Here the patient visited to our hospital, the ECG showed that sinus rhythm and ST-T changed. The CT on chest showed that left lower lung had organic disease, as well as hydropericardium. To be given better therapy, the patient was admited . The patient had no cold intolerance, no chest pain, no syncope, no nausea or vomitting in the course of disease.
One month ago, the patient had undergo an intracoronary stent implantation in USA. He had no ill history of hepatitis, typhoid fever, tuberculosis or other communicable disease. He had no past history of allergy to food or drugs, no history of blood transfusion, either. His immunization are up to date.
The patient was born and live in this location. He had no history of contacting schitosomasis Japonisum contamiate water. He had no history of contacting industrial toxicant, powder, or radioactive material, either. He had no history of other bad hobbies, neither smoking nor drinking. The patient got married in the proper age. His wife is healthy.
His family had no similar ill history. All of family had no communicable disease history of hepatitis, tuberculosis, etc, either genetic disease history like hemophilia, etc.
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