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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
Occupation:
Retired
Marital status:
Married
Date of
admission:
Aug 6th, 2001
Date
of
record:
11Am,
Aug
6th,
2001
Complainer
of
history:
patient’s
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
didn’t
pay
attention
to
it
and
thought
he
had
ate
something
wrong. 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 accepted because of “upper
gastrointestine hemorrhage
and
exsanguine
shock”.
Since the
disease coming on, the patient didn’t
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.
Allergic 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
history
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
living
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
moderately
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
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 vetibulum nasi.
Septum
nasi was in midline. No nares flaring. No
tenderness in