骨科英文病歷

CASE

MedicalNumber:682786

Generalinformation

Name:Guo**

Age:Thirtyfour

Sex:Male

Race:Han

Nationality:China

Maritalstatus:Married

Nativeplace:Tianjin

Address:TianjinMunicipalityJinghaicountyDafengduitownzhendafengdui

village

Occupation:freelancework

Dateofadmission:Jan11st,2001

Dateofrecord:11Am,Jan11st,2001

Complainerofhistory:thepatientherself

Reliability:Reliable

Tel:82422500

Chiefcomplaint:Traumaresulttothearmsandlegsfeeling,activitiesobstaclesabout6hours

Presentillness:sixhoursago,thepatienthadatrafficaccident,suddenlyfeltpaininhisneck,thefeelingofhisarmsandlegslost,hecan’tmove.Atthesametime,hehaveunconsciousbarriers,nodizziness,noheadache,nochestdistress,nodyspnea,nonauseaandvomiting,noabdominalpain,nodiarrhea.Hewassenttotheemergencydepartmentofthehospital,MRIoftheneckshowsC4/5intervertebraldiscbrokenandextruded,Cervicalspinalcordwascompression,andhighsignalchangeatthesamespinalcord,sohewassentthebonespinebecauseofCervicalspinalcordinjurywithtetraplegia

Sinceonset,hisappetiteisgood,bothhisspiritednessandsleeparenormal.Hisdefecationandurinationarenormal,too.Hisweightisnotsignificantlychange

Pasthistory

Operativehistory:Neverundergoinganyoperation.

Infectioushistory:Nohistoryofsevereinfectiousdisease.

Allergichistory:Shewasnotallergictopenicillinorsulfamide.

Reviewofsystems:

Respiratorysystem:nohistoryofSorethroat,chroniccough,sputum,hemoptysis,wheezing,dyspnea,chestpain

Circulatorysystem:nohistoryofPalpitation,dyspneaonexertion,hemoptysis,syncope,edemaoflowerlimbs,precordialpain,hypertention

Alimentarysystem:nohistoryofanorexia,sourregurgitation,belching,nausea,vomitting

Genitourinarysystem:Nohistoryoflumbago,frequentmicturition,urgentmicturition,urodynia,dysuriahematurianocturiapolyuriaoliguriafacialedema

Hematopoieticsystem:Nohistoryoffatigue,dizziness,blurredvision,gingivalbleeding,subcutaneoushemorrhage,ostealgia,epistaxis

Metabolicandendocrinesystem:Nohistoryofexcessiveappetite,anorexia,sweats,coldintolerance,polydipsia,tremorhands,changeofcharacter,obviousobesity,emaciation,hirsutismhair,losingpigmentation,changofsexualfunction,amenorrhea

Musculoskeletalsystem:Nofloatingarthralgia,noarthraliga,noswellingofjoints,nodeformiteiesofjionts,nomyalgia,noatrophyofmuscle.

Neuralsystem:Nohistoryofheadache,dizziness,vertigo,syncope,degenerationofmemory,visualdisturbance,insomnia,disturbanceofconsciousness,tremor,spasm,paralysis,paresthesia

Personalhistory

HewasborninTianjin,andalmostalwayslivedinTianjin.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms,nohistoryofsmoking,nohistoryofdrinking

Obstetricalhistory:getmarriedat24yearsold,havetwochildren,theyare

Breast:Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.

Lungs:

Inspection:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof20/min.Intercostalspacewasnotwideornarrow

Palpation:Thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.

percussion:Resonancewasheard.Noabnormalbreathsoundwasheard.LowerborderswasinthesixthintercostalspaceonCollarbonemidline,theeighthintercostalspaceonmidaxillaryline,thetenthintercostalspaceonscapularline.Spacerangeofmobility:right7.9cm,left7.8cm

Dusculation:breathregular,Nowheezes.Norales.

Heart:

Inspection:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.

Palpation:apeximpulsewasnormal.nothrill,nopercardialfrictionrubs

Percussion:relativecardiacoutlinewasnotenlarge

Right(cm)intercostalspaceleft(cm)

2.6二2.9

3.0三4.5

3.6四5.6

五8.2

Thedistancebetweenclaviclemiddlelinandthemidlinewas9.0cm

Ausculation:Nopericardialfrictionsound.Heartsoundswerestrongandnosplitting.Rate80/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.NoPericardialfrictionrubs

Peripheralvessals:normalpistalshotofbigarteries,noDuroziez’ssign,nowaterhammerpulse,nocapillarypulsation,noparadoxicalpulse,nopulsusalternans

Abdomen:

Inspection:Flatandsymmetry.Nobulgeordepression.Nogastralpatternandintestinalpattern.Novenousdistentionofabdoman.Nopurplestriae.Nosurgicalscarsorhernia

Palpation:soft.Therewasnottendernessandreboundtendernessonabdomenorrenalregion.Liverwasnotreached.Spleenwasnotenlarged.Nomasses.Gallbladdercan’tbetouched,Murphywasnegative.

percussion:bordersofliverdullwasexistence.Upperbordersofliveronrightmidclavicularlinethefifthintercostalspace,whichwas9.8cmfarfromthedownedgeoftheliver.Shiftingdullnessnegative.

ausculation:Borhorygmus5/min,whichwasnotincreasedordecreased.Novascularmurmurs.Nogurglingorperitonealfricatives

Genitalia,rectumandAnus:normal

Specializedexamination:Spinewasnormalandhavenolateralanteriorposteriorprotrudingdeformities.CervicalSpinousprocesshadtendernesspain.Noarticularswellingordeformity.Nomovementsofalllimbs.Physiologicalreflexeswerenotexistent,andthesametopathologicalones.