Patient xx, 34 years old, male, driver, right-handed, junior high school education, Han nationality, northern accent. On June 5438+0991.1.30, the patient collided with a large truck in a car, causing head trauma and coma. He was taken to the local hospital for emergency treatment. At that time, it was diagnosed as brain contusion and cerebral hemorrhage. On admission, MRI showed that the left temporal parietal lobe was softened and local brain atrophy. Clinical diagnosis of admission: brain trauma, right hemiplegia, language disorder. Past medical history: The patient has been healthy and has no special medical history. Language function and related evaluation: 1. Listening function: In daily conversation, patients show that they can't actually communicate with others and can't understand most of their words. The examination results of aphasia show that patients have serious obstacles in listening comprehension. In aphasia examination, the patient's ability to understand nouns, verbs and sentences is seriously lost, especially the ability to understand verbs is the most serious, and he can't execute oral commands. Patients talk a lot, mostly in a long string, which is very smooth, but most of them are meaningless. Patients often say "Praprapra" and often refer to "hands" as "watches". Although the patient's expressive ability is poor, he can sing a few songs that completely move him. Retelling is better. In the investigation, except the loss of sentence-level retelling ability, the correct answer rate of word-level retelling investigation is 100%. Reading: the patient's reading ability is almost completely lost, and reading aloud is better than reading aloud. Writing: the patient's writing ability is almost completely lost, but nouns are copied well, verbs and sentences are not copied, and spontaneous writing and description are not good. Calculation: the calculation ability is well preserved, and all five questions of addition are correct, and all five questions of subtraction are correct, so the multiplication and division method cannot be completed. 2. Brain function: After WAIS-R examination, it was found that the brain function was low, and the patient did not lose the ability to recognize and use.
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Aphasia medical record template
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Aphasia medical record template
Patient xx, 34 years old, male, driver, right-handed, junior high school education, Han nationality, northern accent. On June 5438+0991.1.30, the patient collided with a large truck in a car, causing head trauma and coma. He was taken to the local hospital for emergency treatment. At that time, it was diagnosed as brain contusion and cerebral hemorrhage. On admission, MRI showed that the left temporal parietal lobe was softened and local brain atrophy. Clinical diagnosis of admission: brain trauma, right hemiplegia, language disorder.
Past medical history: The patient has been healthy and has no special medical history.
Language function and related assessment:
1, language function
Page 1
Listen: In daily conversation, patients show that they can't actually communicate with others and can't understand most of their words. The examination results of aphasia show that patients have serious obstacles in listening comprehension. In aphasia examination, the patient's ability to understand nouns, verbs and sentences is seriously lost, especially the ability to understand verbs is the most serious, and he can't execute oral commands.