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1、精品文档Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality:ChinaAddress:NO.35,Dandong Road,JiefangRvenue,Hankou,Hubei.Tel: 857307523Occupation:RetiredMarital status:MarriedDate of admission: Aug 6th, 2001 Date of record: 11Am, Aug
2、6th, 2001Complainer of history:patient sson and wifeReliability:ReliableChiefcomplaint:Upperbellyachetendays,haematemesis,hemafecia and unconsciousness for four hours.Present illness:The patient felt upper bellyache about ten days ago. He didn t pay attention to it and thought he had ate something w
3、rong. At 6 o clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was acceptedbecauseof“uppergastrointestinehemorrhage and exsanguineshock ”.Since the disease coming on, the patien
4、t didnturinate.Past historyThe patient is healthy before.No history of infective diseases. No allergy history of foodand drugs.Past historyOperative history:Never undergoing any operation.Infectious history:No history of severe infectious disease.。1欢迎下载精品文档Allergichistory:He was not allergicto penic
5、illinor sulfamide.Respiratory system:No history of respiratory disease.Circulatory system:No history of precordial pain.Alimentary system:No history of regurgitation.Genitourinary system:No history of genitourinary disease.Hematopoietic system:No history of anemia and mucocutaneousbleeding.Endocrine
6、 system:No acromegaly. No excessive sweats.Kinetic system:No history of confinement of limbs.Neural system:No history of headache or dizziness.Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always livedin Wuhan. His living conditions were good. No bad personal habits and customs.M
7、enstrual history:He is a male patient.Obstetrical history:NoContraceptive history:Not clear.Family history:His parents have both deads.Physical examinationT 36.5 , P 130/min, R 23/min, BP100/60mmHg.He is well developed and moderately nourished. Active position. His consciousness was not clear. His f
8、ace was cadaverous and the skin was not stainedyellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tende
9、rness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness。2欢迎下载精品文档in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi.Septum nasi was in midline. No nares flaring. No tendernes
10、s innasal sinuses.Eye:Bilateraleyelidswerenotswelling.No ptosis.Noentropion.Conjunctivawas not congestive.Sclera was anicteric.Eyeballs were not projected or depressed. Movement was normal.Bilateralpupilswere round and equal in size.Directand indirectpupillary reactions to light were existent.Mouth:
11、 Oral mucous membrane was not smooth, and there wereulcercan be seen. Tongue was in midline.Pharynx was congestive.Tonsils were not enlarged.Neck: Symmetric and of no deformities.No masses. Thyroidwas notenlarged. Trachea was in midline.ChestChestwall:Veins could not be seen easily. No subcutaneouse
12、mphysema. Intercostal space was neither narrowed nor widened.No tenderness.Thorax:Symmetric bilaterally. No deformities.Breast:Symmetric bilaterally.Lungs: Respiratorymovementwas bilaterallysymmetric with thefrequency of 23/min.thoracicexpansion and tactilefremitusweresymmetric bilaterally. No pleur
13、al friction fremitus. Resonancewas heard duringpercussion.No abnormal breathsound was heard.No wheezes. No rales.Heart:No bulge and no abnormal impulse or thrillsin precordialarea. The point of maximum impulse was in 5th left intercostalspace insideofthemid clavicularlineand notdiffuse.Nopericardial
14、frictionsound. Border of the heartwas normal. Heartsounds were strongand no splitting.Rate 150/min.Cardiac rhythmwas not regular. No pathological murmurs.。3欢迎下载精品文档Abdomen: Flatand soft.No bulge or depression.No abdominal wallvaricosis. Gastralintestinal type or peristalses were not seen.Tenderness was obvious around the navel and in upper abdoman.There was not rebound tenderness on abdomenor renalregion.Liverandspleenwas untouched.No masses.Fluidthrillnegative.Shifting dullness negative. Borhorygmus not heard. No vascularmurmurs.Extremities:No articulars
