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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.
Tel:
857307523
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 nasal sinuses.
Eye:
Bilateral
eyelids
were
not
swelling.
No
ptosis.
No
entropion.
Conjunctiva
was
not
congestive.
Sclera
was
anicteric.
Eyeballs
were
not
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