Name: PZ                                        Age: 21 years old

Gender: Male                                   Ethnic group: Han

Nationality:China                              Address; No.1259, Zhonghua Road

Occupation: University student         Marital status: Single

Date of admission: May 27th, 2007   Date of record: 11pm, May 27th, 2007

Complainer of history: the patient     Reliability: Reliable

[chief complaints]

Seven-hour history of right lower abdominal pain with nausea and vomiting.

[present history]

The patient experienced a dull pain in his middle upper abdomen seven hours ago. He didn't receive any treatment. But one hour ago, nausca and vomiting developed and the location of the pain was shifted to the right lower abdomen. So he came to the emergency department of our hospital. The following lab tests are included in the emergent examinations. Blood routine test shows RBC of 4X10/L, wBC of 11.5X10°/L and neutrophil of 80%. So the patient is hospitalized for further diagnosis and treatment.

During his discomfort, he has experienced no heartburn, vomiting of blood or jaundice. He had a normal appetite. His emiction and bowel movement have been normal in color, shape and nature.

[past history] 

The patient has been in good health before. He relates that he has been vaccinated regularly and completely. He denies a history of any surgery, trauma, infectious disease, blood transfusion, or drug allergy.

[system review]

Respiratory system: No cough. wheczing, chest pain, sputum, bloody cough, shortness of breath or difficulty breathing when lying down.

Cardiovascular system: No chest pain or tightness, irregular heart beat, swelling of feet or palpitation.

Digestive system: As above.

Genitourinary system: No painful, frequent or urgent micturition, blood in urine or involuntary loss of urine.

Hematopoietic system:No nose or gum bleeding, hives or difficulty in blood coagulation.

Endocrine system: No excessive sweat, significant change of weight in a short time. darkened skin, polyuria, polydipsia, polyphagia or hands tremblance.

Muscular and skeletal system: No pain in joint, bone, muscle, joint stiffness, swelling or contracture.

Neural and mental system: No headache, dizziness, weakness or numbness of arms and legs. blackout. fainting, convulsions, trouble with speaking, difficulty in walking with balance and controlling bladder or bowels, paralysis, change in memory, loss diminishment or abnormality of sensation, vertigo, tremor or insomnia.

[personal history]

He was born and lived in this city. He denies habits of smoking or drinking. He relates he is single without any sexual partners.

[family history]

He notes his parents are in good health without any serious genetic illnesses in the past.

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