the Diagnosis II

Physical Examination

Temperature: 36.9 ℃        Pulse: 90/min       Respiratory: 20/min  
Blood Pressure 130/80 mmHg

The patient , who developed well and moderately nourished, walked in ward normally and independently. He was in a general mental state and cooperative during the examination. There was no stained yellow, no petechiae, no purpura or pigmentation on skin or mucous membrane. The spider angioma and hepatic palm were not seen, the superficial lymphnodes were not swelling or palpable. The patient whose cranium size is normal had no deforming skull.
The eyelid had no edema, eyeball exertion was normal. The conjunctiva had no hyperemia.The sclera had no stained yellow and cornea was clear.
The pupils of both side, diameter of which was 3 mm, were in the same size, equal roundness. They had no delay on reaction to light. The patient had no auricle deformity. There was no excretions of external auditory canal, no tenderness of mastoid, no audition dysfunction. He had no nasal ala flap. There was no hemorrhage in nasal cavity, no excretions,no nasal septum flank-curvature, no nasal sinus tenderness. There was no abnormal flavour in the patient’s mouth cavity, no mouth libs cyanosis, no gingival bleeding(gums hemorrhage), no cheek mucous membrane erosion or ulcer. He had no deviation of tongue extenison movement. The pharynx had no congestion and the uvula was in the middle line. The tonsil had no enlargement and the voice by larynx sounded clear. The neck was symmetrical and had not rigidity. The carotid pulsation was normal while the jugular vein was full. The trachea was in midline. The thyroid was not enlargement,nodular,and had not tenderness,trill or vascular murmur. The patient’s chest topography was symmetrical and had not any deformity. The chest wall had not varicose veins or subcutaneous emphysema. The movement of respiration was symmetrical. The intercostal space did not increase. The activity of respiration and vocal fremitus were symmetrical. The patient had no sense of pleural friction or subcutaneous crepitus.
The percussion of both lungs showed resonance, and the lower borders were distributed in  the clavicle middle line of the 6th costal interspace, the armpit middle line of the 8th costal interspace and the scapula middle line of the 10th costal interspace. The range of mobility was 6 cm. The respiratory sound of both lungs was coarse. There was no pleural friction rubs while it could be heard that there was moist rales in the base areas of the both lungs. The patient had no bulging in precordial region, no thrills or sense of pericardial friction. The relative cardiac outline didn’t extant. The heart rate was 90 bpm/min and the heart rhythm was regular. There was no any murmurs could be heared on the ausculation area of heart valves, also no pericardial friction rubs. The radial artery was normal. There was no paradoxical pulse, no pulsus alternans or Duroziez’s sign. The patient’s abdomen shape was normal and flat. The peristalsis of stomach and intestine had not been seen. The palpation showed a soft abdomen which had no tenderness or rebound tenderness. The was also no mass in it. The liver and spleen under the rub could not be touched. Murphy’s sign presented negative. The borders of liver dull was normal and the intercostal space shifting dullness presented negative. There was no tenderness in liver and renal region. The borborygmus was 5 bpm/min without succussions plash or vessel bruits. The patient’s genitalia and anus were normal. The spine and extremities had no deformity, mobility was normal. There was no swelling of joints or tenderness.
The myodynamia and muscle tone of all extremities without clubbed fingers were normal. There was no edema on the patient’s both lower limbs. The physiology reflex existed and the pathology reflex had not been induced.

The important laboratory examinations，X-ray，ECG and other result are included)，

1,.ECG (2010-11-09, in this hospital) showed :
  The patient’s sinus heart rhythm and ST-T segment changed

2, CT on chest (2010-11-09, in this hospital) showed:
  The patient’s left lower lung had organic disease, hydropericardium existed and there was a bit of hydrops in the left chest cavity.

3, Echocardiologe (2010-11-09, in this hospital) showed:
The diastolic function of left ventricle decreased and there was hydropericardium

Impression:

Coronary artery disease
Intracoronary stent implantation followed by hypertension(3 Degree, High Danger)
Diabetes mellitus II
Pulmonary infection