GENERAL HISTORY

GENERAL DATA:
Name: 蔡壽	Date of Admission: 910528	
Age:      70      yrs.	ID No.: 000301759C	
Gender: Female	Refer from:	
Date of Birth: 210308	Native: 山西	
Occupation:	Tel or/ Cellular phone: 04-24253717	
Health Status:	E-mail:	

Address: 台中市北屯區后庄一街１４０號５樓

CHIEF COMPLAINTS: 
             Sudden onset of loss of consciousness following falling down accident for 2 days

PRESENT ILLNESS:
  This 70 y/o female is a victim of hypertension under regular medical control for 2years, and major depression disorder. She suffered falling down injury of head 2 days ago with initial loss of consciousness and left limbs weakness for 2 days. Thereafter, she was sent to our ORTH OPD for help, where L-spine was done and showed no specific finding of the image study. 
Then, she was sent to our NS OPD, where under the impression of R/O brain contusion, she was transferred to our SER for further management. 
At SER, brain CT was done and showed head injury with ICH over bilateral frontal regions. Under the impression of head injury with ICH over bilateral frontal regions, she was admitted to our NS ward for further evaluation and treatment.

PAST HISTORY:
1. 	History of hypertension under regular medical control for 2 years
2. 	Smoking (-) and drinking(-)
3. 	Operative history:

FAMILY HISTORY: no other family member has the same disease.

REVIEW OF SYSTEMS:
1.	General: Weight change (-): cachexia appearance (-); fever (-); chills (-); cold sweat (-); night sweat (-); lethargy (-); back pain (-); weakness (-)
2.	Skin: rashes (-); pruritus (-); pigmentation (-); dryness (-); itching (-), Ecchymosis (-); 
3.	Head and neck: dizziness(-); headache (-); vertigo (-); loss of conscious (-); neck stiffness (-)
4.	Eye: glasses (-); blurred vision (-); diplopia (-); itching (-); discharges (-) 
5.	Ears: hearing impairment (-); secretion (-); tinnitus (-)
6.	Nose: smell (normal); sinusitis (-), rhinorrhea (-); epitaxis (-)
7.	Mouth & Throat: taste (-);loss teeth (-); gum bleeding (-); hoarseness (-);
8.	Respiratory: cough (-); sputum (-); hemoptysis (-); SOB (-); 
        chest wall pain (-); 
9.	Cardiovascular: palpitation (-); chest pain (-); orthopnea (-); DOE (-); swelling or edema (-);
10.	Gastrointestinal: pain(-); heart burn (-); poor appetite (-); dysphagia (-); nausea or vomiting(-) fullness(-), constipation(-); diarrhea (-); hemorrhoid (-); tarry stool (-); perianal pain (-);
11.	Genitourinary: dysuria (-); nocturia (-); hematuria (-); frequency (-); urgency (-); urine incontinence (-); hesitancy (-); itching (-); flank pain (-); 
        dribbling (-); knocking pain (-).
12.	Endocrine: goiter (-); tremor (-); edema (-); polyuria (-); 
13.	Neurologic system: conscious impairment (+); dementia (-) ;syncope (-); convulsion (-), numbness (-); Bilateral lower limbs muscle weakness (+); seizures (-); sensory impairment: (-); dysarthria (-), clumsy or ataxia (-) 
14.	Bone, muscular, joint: pain (-); limited of motion (-); injuries or deformities (-); 
15.	Psychiatric: memory loss (-); anxiety (-); depression (-); irritable mood (-)

PHYSICAL EXAMINATIONS:
General appearance
Acute ill-looking, with severe headache.
Vital signs: BP-158/ 97 mmHg, PR-70/min, RR.20/min, B.T.-37.2°C
HEENT: 
Head: no deformity; Eye: light reflex: +/+, anemic conjunctiva, no icteric sclera
ENT: no injected tonsil, no nasal obstruction.

Neck:  Supple, freely movable, normal carotid pulsation, no LAP, no carotid bruit, 
Chest:  Inspection: no accessory muscle used in inspiration; Palpation: 
             no  subcutaneous emphysema; Auscultation: clear breathing sound.
Heart: regular heart beat
Abdomen: Inspection: no stria; Palpation: no palpable mass; Auscultation: 
             normal active bowel sound
Back and Spine: no C-V angle knocking pain, no scoliosis, no kyphosis,
Extremities: : Bilateral lower limbs muscle weakness (+), no clubbing fingers, 
             no LAP, no leg pitting edema, normal movement, good peripheral perfusion,
             and warm
Skin:  no petechia, no ecchymosis, no jaundice, and no pigmentation
Genitalia: normal.
Rectal digital exam: no hemorrhoid 
Neurologic exam: see special chart
Laboratory exam: 
             WBC 17500/cumm, Hb.10.9 g%, Na 142meq, K. 3.7 mg/dl, BUN 12mg/dl, 
             Cr 0.8mg/dl

IMPRESSIONS:
1.	Head injury with ICH, bilateral frontal and contusion of brain 
2.	Hypertension
3.	Major depression

PLANS TO DO:
1. 	On NS admission routine 
2. 	Pre-operative care.
3. 	Arrange surgical intervention
                                                                                                       Intern