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患者男性,23岁,工人。住院号13967。因先天性Ⅲ°腭裂伴双侧唇裂术后畸形,于1985年元月11日收住某县医院外科。9岁时曾双侧Ⅲ°唇裂修补术,无外伤史,过去一向身体健康。入院时情况:体温36.4℃,脉搏80次,血压110/70mmHg,发育、营养良好,见双侧上唇术后错位畸形,Ⅲ°腭裂,最大裂隙3.5cm。化验检查:血色素14g,白血球9500,出凝血时间各1分钟,肝功、心电图、胸透均正常。
Male patient, 23 years old, worker. Hospital number 13967. Due to congenital Ⅲ ° cleft lip cleft palate with bilateral deformities, on January 11, 1985 admitted to a county hospital surgery. 9 years old had double Ⅲ ° cleft lip repair, no history of trauma, the past has always been healthy. Admission conditions: body temperature 36.4 ℃, pulse 80 times, blood pressure 110 / 70mmHg, development, good nutrition, see bilateral upper lip dislocation deformity, Ⅲ ° cleft palate, the maximum cleft 3.5cm. Laboratory tests: hemoglobin 14g, white blood cells 9500, a clotting time of 1 minute, liver function, electrocardiogram, chest X-ray are normal.