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CASE
Medical Number: 682786
General information
Name:
Guo **
Age:
Thirty four
Sex:
Male
Race:
Han
Nationality:
China
Marital status:
Married
Native
place:
Tianjin
Address:
village
Tianjin
Municipality
Jinghai
Occupation:
freelance
work
Date of
admission:
Jan 11st, 2001
Date of record:
11Am, Jan
11st, 2001
Complainer
of
history:
the
patient
herself
Reliability:
Reliable
Tel
:
82422500
county Da feng dui town zhen
dafengdui
Chief
complaint:
Trauma result to
the arms and legs feeling,
activities obstacles
about
6 hours
Present
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 can
’
t move .At the
same
time
,
he
have
unconscious
barriers,
no
dizziness,
no
headache,
no
chest distress ,no dyspnea ,no nausea
and vomiting ,no abdominal pain ,no
diarrhea . He was sent 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
sent the bone
spine because
of
Cervical spinal
cord
injury
with
tetraplegia
Since
onset,
his
appetite
is
good,
both
his
spiritedness
and
sleep
are
normal.
His
defecation
and
urination
are
normal,
weight
is
not
significantly change
Past history
Operative history:
Never
undergoing any operation.
Infectious history:
No
history of severe infectious disease.
Allergic history:
She was
not allergic to penicillin or sulfamide.
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 ,nausea, vomitting
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,
gingival bleeding, subcutaneous
hemorrhage ,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 sexual 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, 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
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