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1、CASEMedicalNumber:GeneralinformationName:Guo**Age:ThirtyfourSex:MaleRace:HanNationality:ChinaMaritalstatus:MarriedNativeplace:TianjinAddress:TianjinMunicipalityJinghaicountyDafengduitownzhendafengduivillageOccupation:freelanceworkDateofadmission:Jan11st,2001Dateofrecord:11Am,Jan1
2、1st,2001Complainerofhistory:thepatientherselfReliability:ReliableTel:Chiefcomplaint:Traumaresulttothearmsandlegsfeeling,activitiesobstaclesabout6hoursPresentillness:sixhoursago,thepatienthadatrafficaccident,suddenlyfeltpaininhisneck,thefeelingofhisarmsandlegslost,hecan’tmove.Atth
3、esametime,hehaveunconsciousbarriers,nodizziness,noheadache,nochestdistress,nodyspnea,nonauseaandvomiting,noabdominalpain,nodiarrhea.Hewassenttotheemergencydepartmentofthehospital,MRIoftheneckshowsC4/5intervertebraldiscbrokenandextruded,Cervicalspinalcordwascompression,andhighsign
4、alchangeatthesamespinalcord,sohewassentthebonespinebecauseofCervicalspinalcordinjurywithtetraplegiaSinceonset,hisappetiteisgood,bothhisspiritednessandsleeparenormal.Hisdefecationandurinationarenormal,too.HisweightisnotsignificantlychangePasthistoryOperativehistory:Neverundergoing
5、anyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Shewasnotallergictopenicillinorsulfamide.Reviewofsystems:Respiratorysystem:nohistoryofSorethroat,chroniccough,sputum,hemoptysis,wheezing,dyspnea,chestpainCirculatorysystem:nohistoryofPalpitation,dys
6、pneaonexertion,hemoptysis,syncope,edemaoflowerlimbs,precordialpain,hypertentionAlimentarysystem:nohistoryofanorexia,sourregurgitation,belching,nausea,vomittingGenitourinarysystem:Nohistoryoflumbago,frequentmicturition,urgentmicturition,urodynia,dysuriahematurianocturiapolyuriaoli
7、guriafacialedemaHematopoieticsystem:Nohistoryoffatigue,dizziness,blurredvision,gingivalbleeding,subcutaneoushemorrhage,ostealgia,epistaxisMetabolicandendocrinesystem:Nohistoryofexcessiveappetite,anorexia,sweats,coldintolerance,polydipsia,tremorhands,changeofcharacter,obviousobesi
8、ty,emaciation,hirsutismhair,losingpigmen
