入院日期: XXXXX

出院日期: XXXXX

门（急）诊诊断：胸痛待查

入院诊断：胸痛待查、冠状动脉粥样硬化心脏病、高血压病

出院诊断：肺栓塞合并腹部感染、冠状动脉粥样硬化心脏病、高血压病、脂肪肝、高胆红素血症？

入院时主要症状及体征

患者因“胸痛３天”入院。查体：神清，查体合作，全身未见瘀点瘀斑，对答切题，未见颈静脉充盈，两肺未及明显干湿啰音，心律尚齐，76次／分，全腹部平软，无明显压痛以及反跳痛，四肢肌力正常，双下肢不肿。

住院期间主要化验结果

2014-6-13 电解质：钾 4.06 mmol/L，钠141 mmol/L, 氯105 mmol/L，二氧化碳结合率20.2 mmol/L ↓；心脏酶：肌酸激酶52 U/L，肌酸酶同工酶0.6 ng/ml，肌钙蛋白Ｉ0.01 ng/ml，肌红蛋白21.4 ng/ml。类风湿因子< 9.94 IU/ml，抗“Ｏ”试验117 IU/mL。凝血全套：凝血酶原时间11.60 s，部分凝血酶原时间35.30 s，凝血酶时间14.40 s，纤维蛋白原1.62 g/L ↑，Ｄ-二聚体测定0.29mg/L。血沉77.00 mm/h ↑。降钙素原< 0.1 ng/ml。

2014-6-16   血沉44.00 mm/h ↑。血常规：白细胞7.10 x 10⁹/L，中性粒细胞比率63.96%，Ｃ反应蛋白15.22 mg/L ↑。肿瘤指标：甲胎蛋白5.13 ng/ml，癌胚抗原1.65 ng/ml，糖类抗原CA-125 4.00 U/mL，糖类抗原 CA 19-9 3.09 U/mL

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住院期间特殊检查结果及重要会诊

6-13　胸部CT：右肺中叶炎症，右侧胸膜增厚；腹部彩超：脂肪肝。心电图：HR84次／分，窦性心律，频发室性早搏。6-19  下肢血管彩超：右侧下肢股总动脉及大隐静脉开口处低回声。6-22  肺动脉造影：双侧肺动脉分支多发肺动脉栓塞，右肺中叶炎症。

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Admittance Date:  XXXXX

Discharge Date:  XXXXX

Outpatient (emergency) Diagnosis: Chest pain pending investigation

Diagnosis at admittance: Chest pain pending investigation, coronary atherosclerosis, hypertension

Diagnosis at discharge: Pulmonary embolism combined with lung infection, coronary atherosclerosis, hypertension, hepatic steatosis, hyperbilirubinemia?

Main Symptoms and Signs at Admittance

Patient admitted because of “chest pain for 3 days.” Examination: Alert, able to cooperate with exam, no petechia or ecchymosis observed anywhere on body; answered questions to the point; no jugular vein engorgement observed; no obvious dry or moist rales in either lung; heart rhythm normal, 76 beats/min; entire abdomen soft, no obvious tenderness or rebound tenderness; muscle strength in limbs normal; neither leg swollen.

Results of Main Tests During Hospitalization

June 13, 2014   Electrolytes: potassium 4.06 mmol/L, sodium 141 mmol/L, chloride 105 mmol/L, CO₂ combining rate 20.2 mmol/L ↓; Cardiac enzymes:  creatine kinase 52 U/L, creatine kinase isoenzymes 0.6 ng/ml, troponin I 0.01 ng/ml, myoglobin 21.4 ng/ml. Rheumatoid factor < 9.94 IU/ml, anti-streptolysin O test 117 IU/mL. Complete coagulation panel: prothrombin time 11.60 s, partial thromboplastin time 35.30 s, thrombin time 14.40 s, fibrinogen 1.62 g/L ↑, D-dimer test 0.29mg/L. Blood sedimentation 77.00 mm/h ↑. Procalcitonin < 0.1 ng/ml.

2014-6-16   Blood sedimentation 44.00 mm/h ↑. Complete blood count: white blood cell count 7.10 x 10⁹/L, granulocyte percentage 63.96%, C-reactive protein 15.22 mg/L ↑. Tumor markers: alpha-feto protein 5.13 ng/ml, carcinoembryonic antigen 1.65 ng/ml, carbohydrate antigen CA-125 4.00 U/mL, carbohydrate antigen CA 19-9 3.09 U/mL

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Results of Specialized Tests and Key Consultations During Hospitalization

6-13 Chest CT: inflammation in right middle lobe of lung, thickening of right pleura. Abdominal ultrasound: hepatic steatosis. Electrocardiograph: HR84 beats/min, sinus rhythm with frequent premature ventricular contractions.  6-19  Lower limb vascular ultrasound: right lower limb common femoral artery and saphenous opening hypoechoic.  6-22  Pulmonary arteriography: multiple bilateral pulmonary branch emboli, inflammation in right middle lobe.

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