Shanghai Changhai Hospital
Medical Record
Name:Department: Emergency department Inpatient ward: Second Ward of Observation Room Bed No.: 60 Admission number: D10 ID No.: 063
Certificate of Diagnosis
Name: Age: 21 Gender: Male Department: Second Ward of Emergency Observation Room ID No.: 0634
Hospitalization Date: April 6, 2021 to September 26, 2021
Diagnosis:
Discharge diagnosis: multiple injuries from falling from height, traumatic medium-sized craniocerebral injury, bilateral frontal lobe contusion and laceration with intracranial pneumatosis, multiple skull fractures, head and face soft tissue contusion, double lung contusion, multiple pelvic fractures, left ilium fracture, left acetabular fracture, left pubic fracture, left ischial fracture, multiple fractures of the left upper limb, comminuted fracture of the left distal humerus with elbow dislocation, comminuted fracture of the left upper ulna, and left upper tibia fracture , left fibular shaft fracture, part of dividing left calf muscle, skin and soft tissue avulsion of right knee, right foot soft tissue contusion. |
Treatment suggestion:
constitutional rest for three months. |
Special Seal for Medical of Emergency Department of Shanghai Changhai Hospital (sealed)
Doctor’s signature (seal): Guangchao Wang
September 26, 2021
Issuing company: Changhai Hospital
This diagnosis certificate must be signed by the doctor with the doctor’s seal and the special seal of the medical institution to be effective.