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Nelitelare
Nilaiaforelis) veal:
PATIENT IDENTITY Date of Admittance: 13° August, 2021
Name: Nana Anderson
Age: Syears
Sex: Female
Your lef (AW L086
MEDICAL REPORT
HISTORY TAKING:
History of Illness: Suffered since 0 minutes before admitted to the hospital due te traffic
accident, History of unconsclausness (9), Nausea (-), Vomiting (+)
Mechanism of trauma: Patient was a passenger in a taxi when the car accident happened.
Physical Cxamination:
General Statue; Moderate Hines /well-nourished/eompos mentis
Vital Sign:
1 120/80 mentig,
Ni Béx/minutes, regular
PL AR 20x imin regulag apontanwour thoracoabdominal type, Symmetrical
§ 26.7 degree Celsius |
Chief Complain: fractured left ankle
LOCAL STATUS
Fractured left ankle eas
br, AED Kleipoo!Oo vo" een aanteon
alekenbula
Jan Tooropstraat, 1061 AE Amsterdam, Netherlands
PATIENT IDENTITY Date of Admittance: 13" August, 2021
Name: Nana Anderson
Age: = J5years
Sex: female
Your Ref: OAW 1086
MEDICAL REPORT
HISTORY TAKING;
Chief Complain: fractured left ankle
History of Hiness: Suffered since JO minutes before admitted to the hospital due to traffic
accident, History of unconsclousness (+), nausea (+), Vomiting (+).
Mechanism of trauma: Patient was a passenger in a taxi when the car accident happened.
Physical Examination;
General Status: Moderate Illness /well-nourlahed/compos ments
Vital Sign:
1120/80 mmlg
N; 8Bx/minutes, regular
PRA 20eLmin regular, spontaneous thoracoabdominal type, Symmetrical
S: 36,7 degree Celsius
LOCAL STATUS
Fractured left ankle
ormity (+), Homatoms (tne va )
Inspection:
rf
De, AEB Kleipool
SAE EER TS AREA ONS HC REIN RAT ARNEL NE ROA REI AS TE NSO SEITE