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Medical Records for Admission
Medical Number:
701721
General information
Name: Zhang Xiaoming
Occupation:
Retired
Age: sixty-five
Marital status: Married
Sex: Male
Date of admission: Aug 9th, 2013
Race: Han
Date of record: 11Am, Aug
9th, 2013
Nationality: China
Complainer of
history: patient
’
s son and
wife
Address: NO.123.
Beijing south road, urumqi
Reliability:
Reliable
Chief
complaint:
Suffering head
trauma for 4 hours.
Present
illness:
The patient
fell to the ground and hurt head for about 4 hours
ago. He didn
’
t pay attention
to it
and thought he had
obviously felt unwell.
At 15
o
’
clock this afternoon he
with repeated headache
and
accompanied
by
nausea
and
vomiting.
His
family
sent
him
to
our
hospital
and
received
emergent treatment. So the patient
was
accepted as
“
head
trauma
”
. Since the disease
coming
on, the patient
didn
’
t urinate.
Past history
The
patient
is
healthy
before.
No diabetes, hypertension, rheumatic
heart disease, tuberculosis,
epilepsy,
asthma,
jaundice,
cerebrovascular
disease.
No
history
of
infective
diseases.
No
allergy
history of food and drugs.
Personal history
He
was
born
in
Urumchi
on
Nov
19th,
1937
and
almost
always
lived
in
Urumchi .
His
living
conditions
were
good.
No
bad
personal
habits
and
customs.
Family history:
His parents
have both cause of death is unknown.
Physical examination
T
36.5
℃
,
P
130/min,
R
23/min,
BP
100/60mmHg.
He
was
well
developed
and
moderately
nourished.
active
lying
position
.His consciousness
was not clear. His
face
was pale and
the
skin
was
not
stained
yellow.
No
cyanosis.
No pigmentation. No skin
eruption. Spider
angioma
was
not
seen.
Superficial
lymph
nodes
were
not
found
enlarged.
Respiratory
movement
was
bilaterally
symmetric
with
the
frequency
of
23/min.
No
pleural
friction
fremitus.
Resonance
was
heard
during
percussion.
No
abnormal
breath
sound
was
heard.
No
wheezes.
No
rales.
Border
of
the
heart
was
normal.
Heart
sounds
were
strong
and
no
splitting.
Rate
150/min.
Cardiac
rhythm
was
regular. No pathological murmurs.
Abdomen was flat and soft. No bulge
or
depression.
No
abdominal
wall
varices.
Gastralintestinal
type
or
peristalses
were
not
seen.
Tenderness
was
not
obvious
around
the
navel
and
in
upper
abdoman.
There
was
not
rebound
tenderness
on
abdomen
or
renal
region.
Liver
and
spleen
was
untouched.
Shifting
dullness negative. No
vascular murmurs. No edema.
Examinations of
nedvous system
Higher
function normal.
Cranial nerves
ⅰ
: normal.
ⅱ
:PERRLA(pupils
equal in reaction to light and accomodation)/
normal fundi and visual fields .
ⅲ
,
ⅳ
,
Ⅵ
: no diplopia / nystagmus.
ⅴ
-
Ⅻ
:
normal.
Upper and lower limbs: power,
tone, coordination, sensation all normal .
J oints and skin
：
Normal..
Physiological
reflexes
were
existent
,without
any
pathological
ones.
The
neck
was
rigid,
and
Kernig
’
s sign was
present.
Investigation
Blood-Rt: Hb 69g/L
RBC 2.70
×
1012/L
WBC
1.1
×
109/L
PLT 120
×
109/L
CT: Subarachnoid hemorrhage
with a small amount of blood present in the
occipital horns of the
lateral
ventricles. Moderate hydrocephalus is also
present.
History summary
1. Patient was male,65 years old
2. Suffering head trauma
for 4 hours.
3. No special
past history.
4. Physical
examination: T 37.5
℃
, P
130/min, R 23/min, BP 100/60mmHg
Physiological
reflexes
were
existent
,without
any
pathological
ones.
The
neck
was
rigid,
and
Kernig
’
s sign was
other positive signs.
5.
investigation information:
Blood-Rt:
Hb 69g/L
RBC
2.70
×
1012/L
WBC 1.1
×
109/L
PLT
120
×
109/L
CT: Subarachnoid hemorrhage with a
small amount of blood present in the occipital
horns of the
lateral ventricles.
Moderate hydrocephalus is also present.
Impression:
traumatic
subarachnoid hemorrhage
Signature: Zongkai Li
入院病例
一般信息
姓名：张晓明
职业：退休
年龄：
65
岁
婚姻状况
：已婚
性别：男
入院日
期：
2012
年
8
月
9
日
民族：
汉
记录时间：
2012
年
8
月
9
日
11:00
国家：中国
病史陈述者：患者儿子和妻子
住址：
乌鲁木齐市北京南路
123
号
可靠程度：可靠
< br>主诉：头部外伤后
4
小时
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