骨科英文病历.docVIP

骨科英文病历 CASE Medical Number: 682786 General information Name: Guo ** Age:Thirty four Sex: Male Race: Han Nationality: China Marital status: Married Native place:Tianjin Address: Tianjin Municipality Jinghai county Da feng dui town zhen dafengdui village Occupation: freelance work Date of admission: Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Tel:Chief complaint: Trauma result to the arms and legs feeling, activities obstacles about 6 hours Present 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 can’t 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 consciousness, tremor, spasm, paralysis, paresthesia Personal 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 drinking Obstetrical history: get married at 24 years old,have two children,they are healthy Family history: Deny family genetic history Physical 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 lymp