脑干出血首程(国外英文资料).docVIP

脑干出血首程(国外英文资料) The martial arts medical school is affiliated to the hospital Name: XXX Codon: XXX Bed: 00 Medical record no. : 000000 ID no. : 0000000000 The first course of illness The time of the month of 2006 Patients, sex, age, cause muscle weakness/unconsciousness/breathing disorder associated with intermittent vomit x hours in 2006 (date) (month) (year) at the outpatient service to brain stem hemorrhage income. Cases of features: History: 1. Because of hospital patients with no obvious cause sudden limb weakness/x hours before unconsciousness/respiratory disturbance between partners with vomiting, gastric contents vomit for coffee samples, hence by family members to the hospital emergency, the emergency line head CT: pons hemorrhage, the bleeding is about - ml. We were hospitalized for further treatment. The patient has been unaware of the disease since the onset of illness, vomiting, no physical convulsions, no two incontinence. Previous history of hypertension -- years, history of diabetes -- years. 2. The body: the body temperature 36.5 ℃, pulse is 96 times/min, breathing 17 times/min, blood pressure 160/90 MMHG. Developing normally, nutrient medium, automatic/passive position, owe/no conscious, body/no/cooperation, whole body skin yellow dye, no bruises, superficial lymph node enlargement. No pale of conjunctiva, sclera, no yellow dye, the pupil/no/etc. Large such as round, light reflex exists/away/dull, mastoid no pressure, no wing flap, oral mucosa pale, pharyngeal hyperemia, bilateral amygdala, no swelling, neck soft passivity, did not see the jugular vein engorgement and carotid artery, abnormal pulse, trachea center, thyroid enlargement, thoracic symmetry, breathe freely/shallow weak/stop, bilateral language fibrillation is normal, double lung percussion sound clear, no abnormal breath sounds. The heart rate qi, the heart tone is strong, not smell and the pathological noise, the abdominal bulbous, not see the gastrointestinal type and the peristaltic