The Second Affiliated Hospital of Soochow University
Problem-Oriented Medical Records for Admission
General data
Name：
Age：
Sex:
Marital status:
连绵的群山像什么>学年Birth of place:
Race:
拿破仑远征埃及
Address:
Occupation:葡萄种植大棚
Complainer:
Reliability:
Time of admission:
Time of record:
History
荆州古城墙
Chief complaint:
History of Prent illness:
Past history:
Previous health status: well ordinary bad
Infectious history:
Allergic history:
History of Trauma and surgery:
Review of systems
Respiratory system:
Circulatory system:
Alimentary system:
Urinary system:
Hematopoietic system:
Endocrine system:
Nervous system:
Motor system：
Personal history：
Birth place: occupation: xual history:
Smoking: N Y about years average pieces per day stopped for years
Alcohol intake: N Y about years average ml per day stopped for years
Marital history: single married spou’s state of health: well bad
Menstrual and childbearing history:
Menstrual period ( )
Menarche age( )---------------------------LMP or age of menopau( )
Menstrual cycle ( )
Menstrual cycle: regular irregular
Amount of flow: litter normal large
Menstrual pain: N Y
Pregnancy: times natural labor: times abortion: times
求导公式Premature delivery: times stillbirth: times
Family history:
Congenital dia: N Y ( )
Health status of parents:
Physical examination
Vital sign
T： ℃, P： /min, R： /min, BP： mmHg.
General appearance
Development: ortho-sthenic type asthenic type sthenic type
Facial feature: normal acute chronic others
Expression: natural painful anxious dreadful indifferent
Position: active mi-recumbent other
Consciousness: aware somnolence confusion stupor coma delirium
Cooperation: well badly
Skin and mucosa
Color: normal red pale cyanosis yellow pigmentation
Lesions: N Y (type and distribution )
Subcutaneous hemorrhage: N Y (type and distribution )
Hair: normal scattering losing(position )
Moisture and temperature: normal cold dry wet
Elasticity: normal reduced
Edema: N Y (position and degree )
Hepatic palm: N Y
Spider angioma: N Y (position and degree )
Other:
Superficial lymph node
non-swelling swelling (position and characteristic )
Head
Cranium size: normal large small
Deformity: N Y (oxycephaly squared skull deforming skull )
Others: tenderness mass sunk (position )
Ear:
Auricles: normal deformity fistula others (left right)
Excretion of external auditory canals: N Y(left right feature )
Tenderness in mastoid area: N Y
Auditory acuity: N Y (left right)
No:
Shape: normal abnormal
Other abnormality: N Y (nasal ala flap obstruction excretions)
Nasal sinus tenderness: N Y (position )
Eye:
Eyelids: normal edema ptosis trichiasis
Eyeballs: normal proptosis(left right) depression (left right)
tremor motion dysfunction (left right)
Conjunctiva: normal edema congestive hemorrhage
Sclera:normal yellow
Cornea: normal abnormal (left right)
Pupils: equal roundness same size unequal (left cm right cm)雨方
Reactions to light: normal delay (left right) disappear (left right)
Other:
Mouth:
Lips: red cyanosis pale herpes fissure
Mucosa: normal abnormal (pale petechia others )
Tongue: normal abnormal (coverings hemorrhage leaning to left or right)
Gums normal swelling pus overflow hemorrhage pigmentation lead line
Tooth: regular edentulous carious teeth
Tonsils: normal enlarged(degree )
Voice: normal hoar
Neck:
Resistance: N Y
Carotid artery pulsation: normal incread decread(left right)
Jugular vein: normal distention high distention
Hepatojugular reflux: (-) (+)
Trachea: middle deviation to (left right)
