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 deads.The 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 present.No 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
主诉：头部外伤后4小时
现病史：患者于4小时前摔倒在地，伤及头部， 受伤后患者未感到明显不适，未给予重视。 在下午15时许，患者感反复头痛，伴有恶心、呕吐。家属急送入我院，给予急救处理， 患者以“头部外伤”收入院，受伤以来，患者无小便。 既往史：患者既往体健，无糖尿病、高血压、风湿性心脏病、肺结核、癫痫、哮喘、黄疸、脑血管疾病。无感染性疾病史。没有食物和药物的过敏史。
个人史：患者出生在乌鲁木齐1937年11月19日, 几乎长期本地居住。患者的生活条件良好。无不良的个人习惯和习俗。
家族史：他的父母均已去世，死因不明。
体格检查 T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. 患者身体健康，营养中等；主动卧位，意识不清，面色苍白，皮肤无黄疸；无黄萎、无色素沉着、无皮肤破溃，无蜘蛛痣，浅表淋巴结无肿大，双侧胸部呼吸运动对称，呼吸频率23 /分钟。无胸膜摩擦音及震颤。共振时听到打击乐器。无异常呼吸音。无喘息。无水泡音，心脏边界正常。心音强大, 无心音分裂。心率150 /分钟。心律正常。无病理性杂音。腹部平坦, 柔软。无隆起或凹陷。无腹壁静脉曲张。未见胃与肠的外型及蠕动。 上腹部及脐周无明显压痛。腹部及肾区无反跳痛。肝脾未触及。移动性浊音阴性。无血管杂音。没有水肿。
神经系统检查
高级神经功能正常。
第一对颅神经：正常。
第二对颅神经：瞳孔对光调节反应等大，正常眼底与视野。 第三、四、九颅神经：无复视和眼球震颤。
第五至十二对颅神经正常。
上下肢：肌力、肌张力、协调、感觉正常。
关节与皮肤：正常。
生理反射存在, 病理反射阴性。颈部僵硬, 克尼格氏征阳性。
检查
血常规：血红蛋白69g/L 红细胞2.70×1012/L 白细胞1.1×109/L 血小板 120×109/L
CT:蛛网膜下腔出血和侧脑室枕角少量出血，存在脑积水。
病例摘要
1. 患者男性，65岁。
2. 头部外伤后4小时。
3. 无特殊既往史。
体格检查：T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg。生理反射存在, 病理反射阴性。颈部僵硬, 克尼格氏征阳性。无其他阳性体征。
4. 辅助检查：血常规：血红蛋白69g/L 红细胞2.70×1012/L 白细胞1.1×109/L 血小板 120×109/L；
CT:蛛网膜下腔出血和侧脑室枕角少量出血，存在脑积水。
初步诊断：外伤性蛛网膜下腔出血 签名：
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