medical record

更新时间:2023-07-22 02:55:02 阅读: 评论:0

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:
表白礼物
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)

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