Medical Records for Admission

(important, must record→) Admission 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 worker 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 for ten days, vomiting coffee ground material for four hours. History of Present Illness: The patient felt upper bellyache about ten days ago. Since it was mild and intermittent, he didn’t pay attention to it and thought he had ate something wrong. The pain would get more severe when he was hungry and could be relieved by eating. He didn’t experience any feeling of reflux. Four hours ago (at 6 o’clock this morning) , before he started having his breakfast, he suddenly vomited coffee ground material, the total volume was nearly 1,000 ml. He felt dizzy but was conscious all the time. He went to toilet once, and found soft tar-like feces, around 100ml. His family sent him to the emergency room of our hospital, and he was admitted to our ward with “upper gastrointestinal hemorrhage”. The patient didn’t urinate for four hours. Past history The patient used to be healthy before. 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

Septum nasi was in midline. No subcutaneous emphysema. Movement was normal. Menstrual history: He is a male patient. reasons unknown. No deformities. well distributed. Thyroid was not enlarged. No bad personal habits and customs. Active position. Tongue was in midline. No tenderness. No cyanosis. Pharynx was congestive. His face was cadaverous and the skin was not stained yellow. Nose: No abnormal discharges were found in vetibulum nasi. No deformities.5℃. No discharges were found in external auditory canals. No tenderness. Breast: Symmetric bilaterally. Conjunctiva was not congestive. No pitting edema. Head Cranium: Hair was black and white. No ptosis. No entropion. Eyeballs were not projected or depressed. Spider angioma was not seen. Bilateral pupils were round and equal in size. No tenderness in mastoid area. No masses. His living conditions were good. Ear: Bilateral auricles were symmetric and of no masses. P 130/min. and there were ulcer can be seen. No tenderness in nasal sinuses. Neck: Symmetric and of no deformities.Wuhan. Palpation: Thoracic expansion and tactile fremitus were symmetric . Trachea was in midline. He is well developed and moderately nourished. No skin eruption. Lungs: Inspection: Respiratory movement was bilaterally symmetric with the frequency of 23/min. Intercostal space was neither narrowed nor widened. No masses. BP 100/60mmHg. Auditory acuity was normal. Family history: His parents have both died at old age. Eye: Bilateral eyelids were not swelling. Obstetrical history: No Contraceptive history: Not clear. No scars. Tonsils were not enlarged. No nares flaring. Mouth: Oral mucous membrane was not smooth. Sclera was anicteric. Superficial lymph nodes were not found enlarged. His consciousness was not clear. Thorax: Symmetric bilaterally. Chest Chestwall: Veins could not be seen easily. No pigmentation. R 23/min. Direct and indirect pupillary reactions to light were existent. Physical examination T 36.

Heart: Inspection: No bulge and no abnormal impulse or thrills in precordial area. . P 130/min. Genitourinary system: Not examined Rectum: Not examined Investigation Blood-Rt(---Hospital. Tenderness was obvious around the navel and in upper abdoman.5℃. Free movements of all limbs. There was not rebound tenderness on abdomen or renal region. No vascular murmurs. No vascular murmurs. Liver and spleen was untouched. 3. Shifting dullness negative. Borhorygmus not heard. Neural system: Physiological reflexes were existent without any pathological ones. Date): Hb 69g/L RBC 2. No pericardial friction sound. Shifting dullness negative.70T/L WBC 1. 1G/L PLT 120G/L History summary 1. Patient was male. Auscultation: Borhorygmus not heard. Physical examination: T 37. Percussion: Border of the heart was normal. There was not rebound tenderness on abdomen or renal region. No pleural friction fremitus. Abdomen: Inspection: Flat. Cardiac rhythm was not regular. No special past history. Upper bellyache for ten days. No rales. Gastralintestinal type or peristalses were not seen. No abdominal wall varicosis. No masses. BP 100/60mmHg Superficial lymph nodes were not found enlarged. Auscultation: Heart sounds were strong and no splitting. 80 years old 2. vomiting coffee ground material for four hours. No masses. no bulge or depression. Auscultation: No abnormal breath sound was heard. 4. No other positive signs. Fluid thrill negative. Percussion: Fluid thrill negative. Gastralintestinal type or peristalses were not seen. Percussion: Resonance was heard during percussion. Tenderness was obvious around the navel and in upper abdoman.bilaterally. R 23/min. No wheezes. Liver and spleen was untouched. No pathological murmurs. No abdominal wall varicosis. Extremities: No articular swelling. Rate 150/min. Palpation: Soft. Palpation: The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse.

80T/L WBC 1.5.1G/L PLT 120G/L Impression: Upper Gastrointestinal Hemorrhage Peptic Ulcer? Signature: John Smith (student ID) . investigation information: Blood-Rt: Hb 69g/L RBC 2.

Sign up to vote on this title
UsefulNot useful