心内科英文病历

MedicalRecordsforAdmissonMedicalNumber:701721GeneralinformationName:LiuSideAge:EightySex:MaleRace:HanNationality:ChinaAddress:NO.35,DandongRoad,JiefangRvenue,Hankou,Hubei.Tel:[phone]Occupation:RetiredMaritalstatus:MarriedDateofadmission:Aug6th,2001Dateofrecord:11Am,Aug6th,2001Complainerofhistory:patient’ssonandwifeReliability:ReliableChiefcomplaint:Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours.Presentillness:Thepatientfeltupperbellyacheabouttendaysago.Hedidn’tpayattentiontoitandthoughthehadatesomethingwrong.At6o’clockthismorninghefaintedandrejectedlotsofbloodandgore.Thenhemafeciabegan.Hisfamilysenthimtoourhospitalandreceivedemergenttreatment.Sothepatientwasacceptedbecauseof“uppergastrointestinehemorrhageandexsanguineshock”.Sincethediseasecomingon,thepatientdidn’turinate.PasthistoryThepatientishealthybefore.Nohistoryofinfectivediseases.Noallergyhistoryoffoodanddrugs.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Hewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryHewasborninWuhanonNov19th,1921andalmostalwayslivedinWuhan.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Heisamalepatient.Obstetricalhistory:NoContraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdeads.PhysicalexaminationT36.5℃,P130/min,R23/min,BP100/60mmHg.Heiswelldevelopedandmoderatelynourished.Activeposition.Hisconsciousnesswasnotclear.Hisfacewascadaverousandtheskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotfoundenlarged.HeadCranium:Hairwasblackandwhite,welldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Oralmucousmembranewasnotsmooth,andtherewereulcercanbeseen.Tonguewasinmidline.Pharynxwascongestive.Tonsilswerenotenlarged.Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.Thorax:Symmetricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof23/min.thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate150/min.Cardiacrhythmwasnotregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.Genitourinarysystem:Notexamed.Rectum:notexanedInvestigationBlood-Rt:Hb69g/LRBC2.70T/LWBC1.1G/LPLT120G/LHistorysummary1.Patientwasmale,80yearsold2.Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours.3.Nospecialpasthistory.4.Physicalexamination:T37.5℃,P130/min,R23/min,BP100/60mmHgSuperficiallymphnodeswerenotfoundenlarged.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.Nootherpositivesigns.5.investigationinformation:Blood-Rt:Hb69g/LRBC2.80T/LWBC1.1G/LPLT120G/LImpression:uppergastrointestinehemorrhageExsanguineshockSignature:HeLin(95-10033)