Medical Records for Admission
Medical Number: 701721
General information
Name: Yu Changsheng Age: Forty eight Sex: Male Race: Han Nationality: China
Address: NO.168, Baodong Road, Shanghai.
Occupation: Unknown Marital status: Married
Date of admission: 14:21, July 9th, 2010 Date of record: 17:10, July 9th, 2010 Complainer of history: Patient’s himself Reliability: Reliable
Chief complaint: Epigastric discomfort for one month, melena for five days.
Present illness:
The patient felt epigastric discomfort about one month ago without any reasons. And found melena 5 days ago. Pitch-like, shaping, frequency is normal without abdominal pain, sour regurgitation, nausea and vomiting. Because the patient had hemorrhoids, so he did not pay much attention. 2010/7/9, the patient felt anergy, weakness, cold sweat, and saw the doctor in the emergency ward. The BP was 80/60mmHg, BRT: RBC 3.7*1012/L, Hb 108g/L, WBC 4.9*109/L, N% 67.3%. The doctor considered it was hemorrhage of upper digestive tract and gave him Omeprazole 40 mg intravenous push and anti inflammation, fluid replacement. The patient felt better. The next day gastroscope showed gastric angle ulcer, chronic gastritis. So the patient was admitted to our ward for further treatment.
During the course: General status normal. Spirit, sleep, appetite normal. Urine normal. The weight lost 10 Kg.
Past history
A history of peptic ulcer and hemorrhoids. No history of infective diseases.
No history of operation or trauma. No blood transfusion history. No allergy history.
Personal history
He was born and lived in Shanghai. A history of smoking for 30 years. No exposure history to epidemic area of infectious disease.
Family history: His father was died of stroke and mother was died of cancer. His children was healthy. No communicable diseases and genetic disease.
Physical examination
T 37℃, P 80/min, R 20/min, BP 110/70mmHg. He was well developed and moderately nourished. Active position. His consciousness was clear. His face was pale and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. Superficial lymph nodes were not found enlarged. Respiratory movement was bilaterally symmetric with the frequency of 20/min. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound. No wheezes. No rales. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs. Abdomen was flat and soft. No bulge or depression. No abdominal wall varices. Gastral intestinal type or peristalses were not seen. No tenderness and rebound tenderness. Liver and spleen was untouched. No masses. Shifting dullness negative. No vascular murmurs. No edema.
Physiological reflexes were existent without any pathological ones.
Investigation
2010/7/8, BRT: RBC 3.7*1012/L, Hb 108g/L, WBC 4.9*109/L, N% 67.3%.
2010/7/9, Gastroscopes: gastric angle ulcer, chronic gastritis.
History summary
1. Patient was Male, 48 years old
2. Epigastric discomfort for one month, melena for five days. 3. A history of peptic ulcer and hemorrhoids.
4. Physical examination: T 37℃, P 80/min, R 20/min, BP 110/70mmHg. Superficial lymph nodes were not found enlarged. Heart rate was 80/min. Cardiac rhythm was regular. No tenderness and rebound tenderness. Liver and spleen was untouched. No masses. Shifting dullness negative. No other positive signs.
5. Investigation information: 2010/7/8 BRT: RBC 3.7*1012/L, Hb 108g/L, WBC 4.9*109/L, N% 67.3%. 2010/7/9 Gastroscopes: gastric angle ulcer, chronic gastritis.
Impression: hemorrhage of upper digestive tract stomach ulcer(?); stomach cancer(?)
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