骨科英文病历.doc

CASE Medical Number: 682786General informationName: Guo *Age:Thirty fourSex: MaleRace: HanNationality: ChinaMarital status: MarriedNative place:TianjinAddress: Tianjin Municipality Jinghai county Da feng dui town zhen dafengdui villageOccupation: freelance workDate of admission: Jan 11st, 2001Date of record: 11Am, Jan 11st, 2001Complainer of history: the patient herselfReliability: ReliableTel: 82422500Chief complaint: Trauma result to the arms and legs feeling, activities obstacles about 6 hoursPresent 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 cant 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, too.His 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 painCirculatory 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, paresthesiaPersonal 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 drinkingObstetrical history: get married at 24 years old,have two children,they are healthyFamily history: Deny family genetic historyPhysical examination Vital signs:T 36.5, P 68/min, R 16/min, BP 129/90mmHg. General condition:He is well developed and moderately nourished. Passive position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Lymphnodes: Superficial lymph nodes were not enlarged or pressing pain.Head Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness. Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent. Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.Chest Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine. Lungs: Inspection: Respiratory movement was bilaterally symmetric with the frequency of 20/min. Intercostal space was not wide or narrowPalpation: Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. percussion: Resonance was heard. No abnormal breath sound was heard. Lower borders was in the sixth intercostal space on Collarbone midline, the eighth intercostal space on midaxillary line ,the tenth intercostal space on scapular line. Space range of mobility:right 7.9cm,left 7.8cmDusculation: breath regular, No wheezes. No rales. Heart: Inspection: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. Palpation : apex impulse was normal .no thrill, no percardial friction rubsPercussion: relative cardiac outline was not enlarge Right(cm) intercostal space left(cm) 2.6 二 2.9 3.0 三 4.5 3.6 四 5.6 五 8.2 The distance between clavicle middle lin and the midline was 9.0cmAusculation: No pericardial friction sound. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs.No Pericardial friction rubsPeripheral vessals: normal pistal shot of big arteries,no Duroziezs sign ,no water hammer pulse, no capillary pulsation, no paradoxical pulse, no pulsus alternansAbdomen: Inspection: Flat and symmetry. No bulge or depression .No gastral pattern and intestinal pattern. No venous distention of abdoman . No purple striae . No surgical scars or herniaPalpation: soft. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Gallbladder cant be touched,Murphy was negative. percussion: borders of liver dull was existence. Upper borders of liver on right midclavicular line the fifth intercostal space,which was 9.8cm far from the down edge of the liver. Shifting dullness negative.ausculation : Borhorygmus 5/min, which was not increased or decreased. No vascular murmurs.No gurgling or peritoneal fricativesGenitalia ,rectum and Anus: normal Specialized examination: Spine was normal and have no lateral anterior posterior protruding deformities.