大学精品课件:消化科英文病历.doc
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- 大学 精品 课件 消化 英文 病历
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1、 Medical Records for Admisson Medical Number: 701721 General information Name: Liu Side Age: Eighty Sex: Male Race: Han Nationality: China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: Retired Marital status: Married Date of admission: Aug 6th, 2001 Date of
2、record: 11Am, Aug 6th, 2001 Complainer of history: patients son and wife Reliability: Reliable Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. Present illness: The patient felt upper bellyache about ten days ago. He didnt pay attention to it and
3、 thought he had ate something wrong. At 6 oclock 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 accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Sin
4、ce the disease coming on, the patient didnt urinate. Past history The patient is healthy before. No history of infective diseases. No allergy history of food and drugs. Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allerg
5、ic history: He was not allergic to penicillin or 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 hi
6、story of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness. Personal history He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His livi
7、ng conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient. Obstetrical history: No Contraceptive history: Not clear. Family history: His parents have both deads. Physical examination T 36.5, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moder
8、ately nourished. Active position. His consciousness was not clear. His face was cadaverous and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged. Head Cranium: Hair was black
9、 and white, well distributed. No deformities. No scars. No masses. No tenderness. Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetib
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