护理病历2013.1(国外英文资料).docVIP

护理病历2013.1 Hospital nursing history (-) in maitreya county. Admission assessment The date of the diagnosis of the family of the old age of the family of the family of the family of the family of the family of the family of the family of the family of the family of the family of the family of the family of the family of the family of the family of the family of the Name shi lianying female age 64 professional peasant ethnic han nationality The marital status of junior high school (unmarried, married, widowed) is married Religious beliefs (have, not) have no history of allergies (no, no) Admission mode (walking, holding, wheelchair, flat car, stretcher, back, etc.) Admission diagnosis: stroke western medicine 1, cerebral embolism, left cervical artery system 2, hypertension 2, extremely high risk group The chief complaint shall not be in a coma for 10 days Main disease patients (causes + primary symptom) children were v: 10 days before the hospital patients for 2 hours dizziness, should not be 10 minutes of call mile county hospital make a diagnosis and give treatment, sent to the relevant examination diagnosis as follows: 1, cerebral embolism, the left internal carotid artery system 2, high blood pressure level 2, extremely high risk group. After five days of hospitalization, the patient was still in a coma. The patients family signed the hospital and returned home. Returned home did not make special processing, aiming a liquid pap, nasogastric feeding patients in strong stimulated today can open by oneself, family members in order to further make a diagnosis and give treatment, call an ambulance sent to our hospital, in our emergency department with cerebral embolism, high blood pressure into my hospital treatment. Admission to the present disease: coma, cannot speak, the limb cannot move, cannot eat by oneself, leave the canal feeding tube, leave the urinary canal open, defecate. Past medical history (diagnosis + time + cure) has a history of hypertension six years