骨科英文病历

更新时间:2023-05-20 11:56:24 阅读: 评论:0

CASE
  Medical Number: 682786
General information

Name: Guo **除皱纹
Age:Thirty four
Sex: Male
Race: Han
Nationality: China
Marital status: Married
Native place:Tianjin
Address: Tianjin Municipality Jinghai county Da feng dui town zhen dafengdui
village
Occupation: freelance work
Date of admission: Jan 11st, 2001
Date of record: 11Am, Jan 11st, 2001
Complainer of history: the patient herlf
Reliability: Reliable
Tel: 82422500
Chief complaint: Trauma result to the arms and legs feeling, 新婚四字贺语activities obstacles about 6 hours
Prent illness: six hours ago, the patient had a traffic accident,suddenly felt pain in his
neck ,the feeling of his arms and legs lost,he cant move .At the same time , he have unconscious barriers, no dizziness, no headache, no chest distress ,no dyspnea ,no naua and vomiting ,no abdominal pain ,no diarrhea . He was nt to the emergency department of  the hospital , MRI of the neck shows C4/5 intervertebral disc broken and extruded , Cervical spinal cord was compression, and high signal change at the same spinal cord,so he was nt the bone spine becau of Cervical spinal cord injury with tetraplegia
  Since ont, his appetite 宝宝掉头发is good, both his spiritedness and sleep are normal. His defecation and urination are normal, too.His weight is not significantly change
                                           
Past history
Operative history: Never undergoing any operation.
Infectious history: No history of vere infectious dia.
Allergic history: She was not allergic to penicillin or sulfamide.云南风景
Review of systems:
Respiratory system: no history of Sore throat, chronic cough, sputum, hemoptysis , wheezing , dyspnea , chest pain
Circulatory system: no history of Palpitation, dyspnea on exertion, hemoptysis , syncope, edema of lower limbs, precordial pain ,hypertention
Alimentary system: no history of anorexia , sour regurgitation , belching ,naua, vomitting
清晰造句 Genitourinary system: No history of lumbago, frequent micturition, urgent micturition, urodynia , dysuria hematuria nocturia polyuria oliguria facial edema
Hematopoietic system: No history of fatigue, dizziness, blurred vision师德师风活动方案, gingival bleeding, subcutaneous hemorrhage sunday怎么读,ostealgia ,epistaxis
Metabolic and endocrine system: No history of excessive appetite, anorexia, sweats, cold intolerance, polydipsia, tremor hands, change of character, obvious obesity, emaciation, hirsutism hair, losing pigmentation, chang of xual function, amenorrhea
Musculoskeletal system: No floating arthralgia,no arthraliga ,no swelling of joints, no deformiteies of jionts ,no myalgia ,no atrophy of muscle.
Neural system: No history of headache ,dizziness, vertigo, syncope, degeneration of memory, visual disturbance, insomnia, disturbance of consciousness, tremor, spasm, paralysis,芝麻薄脆饼 paresthesia
Personal history
He was born in Tianjin, and almost always lived inTianjin. His living conditions were good. No bad personal habits and customs,no history of smoking,no history of drinking
Obstetrical history: get married at 24 years old,have two children,they are healthy

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