Admission record name: place of birth: gender: occupation: age: nationality: marriage: address: admission time: 20 years 10 month Record date: 20 years 10 month medical history Statement: The patient complained of cough and expectoration for x months, which aggravated the current medical history for x days: The patient reported that he had no obvious cause of cough x months ago and occasionally coughed up white sticky phlegm. No hoarseness, no night sweats, no fear of cold and fever, no dizziness and headache, no chest tightness and shortness of breath, no chest pain and palpitations, no nausea and vomiting, no abdominal distension and abdominal pain, which was not taken seriously at that time. X days ago, the above symptoms got worse. On1October 20th, she went to XX Hospital and was given anti-inflammatory and other symptomatic treatment for X days (drug name unknown). The symptoms have not been significantly alleviated. CT examination showed: "The nature of lesions in the upper left lung remains to be investigated: lung cancer? Tuberculosis? " . Now the patient comes to our hospital for further diagnosis and treatment and lives in our department. Since the onset, the patient's spirit, sleep, appetite and defecation are basically normal, and there is no obvious weight loss in the near future. Past medical history: past health, denial of contact history with infectious diseases such as hepatitis and tuberculosis, no history of blood transfusion after traumatic operation, no history of drug allergy, and unknown history of prevention of contact.

Personal medical history: born in the country of origin, not living in other places for a long time, no history of contact with water and poisons caused by schistosomiasis, smoking for XX years, XX cigarettes/day, quitting smoking for XX days, drinking for XX years, abstaining from alcohol for XX days, with regular daily life and acceptable living environment. Menstrual history:1June 20th, March (menarche age: XX years old, menstrual days: X-X days, cycle: XX-XX days, last menstrual period: month and day), moderate menstrual flow, no dysmenorrhea and blood clots, and leucorrhea without peculiar smell. Marriage and childbearing history: married at the age of XX, with X children and X daughters, and family members are in good health. Family history: there is no similar disease history and genetic disease history in the family. Physical examination: t: 37. 1℃, p: 80 times/min, r: 20 times/min, BP: 120/70mmhg, wt: 50kg. Normal development, moderate nutrition, automatic posture, cooperation between spirit and sobriety. There are no yellow spots on the skin and sclera of the whole body, and superficial lymph nodes are not swollen. The facial features of the skull are normal in shape, with equal pupils, about 3mm in diameter, sensitive to light reflection, no restlessness in the nasal alar, no abnormal secretion in the external auditory canal, no cyanosis in the mouth and lips, no congestion in the pharynx, and no swelling in the bilateral tonsils. The neck is soft, the jugular vein is not dilated, the trachea is basically centered, and the thyroid gland is not enlarged. The chest physical examination showed the specialist situation. The abdomen is flat and soft, no varicose veins of abdominal wall, gastrointestinal type and peristalsis waves are found, no tenderness and rebound pain are found in the whole abdomen, Murphy sign is negative, liver and spleen can be touched under ribs, moving dullness is negative, no knocking pain is found in both kidneys, bowel sounds are 3 times per minute, the tone is not high, and no abnormality is found in external genitals. The spine and limbs are basically normal and can move freely. There is no swelling of the lower limbs, knee reflex exists, and Creutzfeldt-Burk and Pap's sign are not drawn. Specialist situation: the chest is symmetrical without deformity, breathing and movement are free, the tremors on both sides are basically normal, the tapping sound is clear, and the breathing sounds of both lungs are clear without rales. There is no uplift in the precordial region, no uplifting apical pulsation, and apical pulsation at 0.5cm between the fifth ribs of the left clavicle midline, no tremor, small cardiac boundary, 80 beats/min, regular rhythm and no murmur. There are no swollen lymph nodes on the clavicle and neck. No clubbed fingers (toes).

Outpatient Information: Admission Diagnosis: Signature: