General information

Name OccupationMarital status

Age Date of admission

Sex Date of record

RaceNationalityAddress Complainer of historyReliability: Reliable Chief complaint

The patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing.

History of present illness

The patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, went swimming again. Now the condition is more serious. He has a high fever with 39℃ that is accompanied by shaking chills. He has a bad cough with no-blood sputum. When he takes a deep breath, it even hurts.

Past medical history

The patient is health before.No history of infective disease.No allergy history of food and drugs.No operative history.No disease history in other system.

Personal history

He was born in XXX on XXXX and almost always lives in XXX. His living conditions were good. No bad personal habits and customs.

Menstrual history: He is a male patient.

Family history: His parents are both alive.

Physical examination

General: T P R BP W H. The patient is a well-developed, well-nourished adult male. HEENT: PERRL, EMOI, small oral aperture.

Neck: JVP to angle of jaw, 2+ carotid pulses, full range of motion.

Cardiac: RRR, normal S1,S2, distant heart sounds.

Chest wall: No subcutaneous emphysema. No tenderness.

Thorax: Symmetric bilaterally.

Breast: Symmetric bilaterally.

Lungs: Respiratory movement is bilaterally asymmetric with the frequency of 24/min. We can hear

coarse breathingwhen listening to a portion of the chest with a stethoscope. There are moist rales on bilateral inferior lung.

Heart: Border of the heart is normal. Heart sounds are strong and no splitting. Rate 150/min. No

pathological murmurs.

Abdomen: Flat and soft. No abdominal wall varicose. There is no rebound tenderness on abdomen or

renal region. Liver and spleen are untouched.

Skin: No pigmentation. No pitting edema. No skin eruption.

Extremities: No articular swelling. All limbs can free move.

Genitourinary system: Not examed.

Rectum: Not examed.

Neural system: Physiological reflexes are existent without pathological ones.

Investigation

Chest X-ray: Lamellar shadow can be seen in middle and inferior lobe of right lung. The right lung is seriously infected. The volume of useful lung is reduced because of the collection of fluid around the lung.