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1、精选优质文档-倾情为你奉上Division: _ Ward: _ Bed: _ Case No. _Name: _ Sex: _ Age: _ Nation: _ Birth Place: _ Marital Status:_Work-organization & Occupation: _Living Address & Tel: _Date of admission: _Date of history taken:_ Informant:_Chief Complaint: _History of Present Illness: _Past History:General Health S
2、tatus: 1.good 2.moderate 3.poorDisease history: (if any, please write down the date of onset, brief diagnostic and therapeutic course, and the results.)Respiratory system:1. None 2.Repeated pharyngeal pain 3.chronic cough 4.expectoration: 5. Hemoptysis 6.asthma 7.dyspnea 8.chest pain_Circulatory sys
3、tem:1.None 2.Palpitation 3.exertional dyspnea 4.cyanosis 5.hemoptysis 6.Edema of lower extremities 7.chest pain 8.syncope 9.hypertension _Digestive system: 1.None 2.Anorexia 3.dysphagia 4.sour regurgitation 5.eructation 6.nausea 7.Emesis 8.melena 9.abdominal pain 10.diarrhea 11.hematemesis 12.Hemato
4、chezia 13.jaundice _Urinary system: 1.None 2.Lumbar pain 3.urinary frequency 4.urinary urgency 5.dysuria 6.oliguria 7.polyuria 8.retention of urine 9.incontinence of urine 10.hematuria 11.Pyuria 12.nocturia 13.puffy face _Hematopoietic system: 1.None 2.Fatigue 3.dizziness 4.gingival hemorrhage 5.epi
5、staxis 6.subcutaneous hemorrhage _Metabolic and endocrine system: 1.None 2.Bulimia 3.anorexia 4.hot intolerance 5.cold intolerance 6.hyperhidrosis 7.Polydipsia 8.amenorrhea 9.tremor of hands 10.character change 11.Marked obesity 12.marked emaciation 13.hirsutism 14.alopecia 15.Hyperpigmentation 16.s
6、exual function change_Neurological system:1.None 2.Dizziness 3.headache 4.paresthesia 5.hypomnesis 6. Visual disturbance 7.Insomnia 8.somnolence 9.syncope 10.convulsion 11.Disturbance of consciousness 12.paralysis 13. vertigo _Reproductive system:1.None 2.others_Musculoskeletal system:1.None 2.Migra
7、ting arthralgia 3.arthralgia 4.artrcocele 5.arthremia 6.Dysarthrosis 7.myalgia 8.muscular atrophy _Infectious Disease: 1.None 2.Typhoid fever 3.Dysentery 4.Malaria 4.Schistosomiasis 4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever 9.others_Vaccine inoculation:1.None 2.Yes 3.Not clearVacci
8、ne detail _Trauma and/or operation history: Operations:1.None 2.Yes Operation details:_ Traumas:1.None 2.Yes Trauma details:_Blood transfusion history:1.None 2.Yes ( 1.Whole blood 2.Plasma 3.Ingredient transfusion) Blood type:_ Transfusion time:_ Transfusion reaction 1.None 2.Yes Clinic manifestatio
9、n:_Allergic history: 1.None 2.Yes 3.Not clearallergen:_clinical manifestation:_Personal history:Custom living address:_Resident history in endemic disease area:_Smoking: 1.No 2.Yes Average _pieces per day; about_years Giving-up 1.No 2.Yes (Time:_)Drinking: 1.No 2.YesAverage _grams per day; about _ye
10、ars Giving-up 1.No 2.Yes(Time:_)Drug abuse:1.No 2.Yes Drug names:_Marital and obstetrical history:Married age: _years old Pregnancy _times Labor _times (1.Natural labor: _times 2.Operative labor: _times 3.Natural abortion: _times 4.Artificial abortion: _times 5.Premature labor:_times 6.stillbirth_ti
11、mes) Health status of the Mate: 1.Well 2.Not fine Details: _Menstrual history:Menarchal age: _ Duration _day Interval _daysLast menstrual period: _ Menopausal age: _years oldAmount of flow: 1.small 2. moderate 3. large Dysmenorrheal: 1. presence 2.absence Menstrual irregularity 1. No 2.YesFamily his
12、tory: (especially pay attention to the infectious and hereditary disease related to the present illness)Father: 1.healthy 2.ill:_ 3.deceased cause: _Mother:1.healthy 2.ill:_ 3.deceased cause: _Others: _ The anterior statement was agreed by the informant. Signature of informant: Datetime: Physical Ex
13、aminationVital signs: Temperature:_0C Blood pressure:_/_mmHg Pulse: _ bpm (1.regular 2.irregular_)Respiration: _bpm (1.regular 2.irregular_)General conditions:Development: 1.Normal 2.Hypoplasia 3.Hyperplasia Nutrition: 1.good 2.moderate 3.poor 4.cachexiaFacial expression: 1.normal 2.acute 3.chronic
14、other_Habitus: 1.asthenic type 2.sthenic type 3.ortho-thenic typePosition: 1.active 2.positive pulsive 4.other_ Consciousness: 1.clear 2.somnolence 3.confusion 4.stupor 5.slight coma 6.mediate coma 7.deep coma 8.delirium Cooperation: 1Yes 2.No Gait: 1.normal 2.abnormal_Skin and mucosa:Color: 1.norma
15、l 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentationSkin eruption:1.No 2.Yes( type: _distribution:_)Subcutaneous bleeding: 1.no 2.yes (type:_distribution:_) Edema:1. no 2.yes ( location and degree_)Hair: 1.normal 2.abnormal(details_) Temperature and moisture: normal cold warm dry moist dehydratio
16、n Liver palmar : 1.no 2.yes Spider angioma (location:_) Others: _Lymph nodes: enlargement of superficial lymph node: 1. no 2.yesDescription: _Head:Skull size:1.normal 2.abnormal (description:_) Skull shape:1.normal 2.abnormal(description:_) Hair distribution :1.normal 2.abnormal(description:_) Other
17、s:_Eye: exophthalmos:_eyelid:_conjunctiva:_ sclera:_Cornea:_ Pupil: 1.equally round and in size 2.unequal (R_mm L_mm) Pupil reflex: 1.normal 2.delayed (R_s L_s ) 3.absent (R_L_) others:_Ear: Auricle 1.normal 2.desformation (description:_)Discharge of external auditory canal:1.no 2.yes (1.left 2.righ
18、t quality:_) Mastoid tenderness 1.no 2.yes (1.left 2.right quality:_) Disturbance of auditory acuity:1.no 2.yes(1.left 2.right description:_) Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality_) Tenderness over paranasal sinuses:1.no 2.yes (location:_)Mouth: Lip_Mucosa_Tongue
19、_Teeth:1.normal 2. Agomphiasis 3. Eurodontia 4.others:_ Gum :1.normal 2.abnormal (Description_) Tonsil:_Pharynx:_ Sound: 1.normal 2.hoarseness 3.others:_ Neck: Neck rigidity 1.no 2.yes (_transvers fingers)Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distentionTrachea location: 1
20、.middle 2.deviation (1.leftward_2.rightward_)Hepatojugular vein reflux: 1. negative 2.positive Thyroid: 1.normal 2.enlarged _ 3.bruit (1.no 2.yes _) Chest:Chest wall: 1.normal 2.barrel chest 3.prominence or retraction: ( left_right_Precordial prominence_) Percussion pain over sternum 1.No 2.Yes Brea
21、st: 1.Normal 2.abnormal _ Lung: Inspection: respiratory movement 1.normal 2.abnormal_ Palpation: vocal tactile fremitus:1.normal 2.abnormal _ pleural rubbing sensation:1.no 2.yes_ Subcutaneous crepitus sensation:1.no 2.yes_ Percussion:1. resonance 2. Hyperresonance &location_ 3 Flatness&location_ 4.
22、 dullness & location:_ 5.tympany &location:_lower border of lung: (detailed percussion in respiratory disease) midclavicular line : R:_intercostae L:_intercostaemidaxillary line: R:_intercostae L:_intercostaescapular line: R:_intercostae L:_intercostaemovement of lower borders:R:_cmL:_cm Auscultatio
23、n: Breathing sound : 1.normal 2.abnormal _ Rales:1.no 2.yes_ Heart: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuse Subxiphoid pulsation: 1.no 2.yes Location of apex beat: 1.normal 2.shift (_ intercosta, distance away from left MCL_cm) Palpation: Apical pulsation:1. normal 2.lift
24、ing apex impulse 3.negative pulsation Thrill:1.no 2.yes(location:_ phase:_) Percussion: relative dullness border: 1.normal 2.abnormal Right(cm)Anterior midlineLeft(cm)IIIIIIVV(Distance between Anterior Medline and left MCL _cm) Auscultation: Heart rate:_bpm Rhythm:1.regular 2.irregular_ Heart sound:
25、 1.normal 2.abnormal_ Extra sound: 1.no 2.S3 3.S4 4. opening snap P2_ A2_Pericardial friction sound:1.no 2.yes Murmur: 1.no 2.yes (location_phase_ quality_intensity_ transmission_ effects of position_ effects of respiration_ Peripheral vascular signs: 1.None 2.paradoxical pulse 3.pulsus alternans 4.
26、 Water hammer pulse 5.capillary pulsation 6.pulse deficit 7.Pistol shot sound 8.Duroziez signAbdomen: Inspection: Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-belly Gastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yes Abdominal vein varicosis 1.no 2.yes(direction:_ ) Operation scar1.no 2.yes
27、 _Palpation: 1.soft 2. tensive (location:_)Tenderness: 1.no 2.yes(location:_)Rebound tenderness:1.no 2.yes(location:_)Fluctuation: 1.present 2.abscent Succussion splash: 1.negative 2.positive Liver:_ Gallbladder: _Murphy sign:_ Spleen:_ Kidneys:_ Abdominal mass:_ Others:_ Percussion: Liver dullness
28、border: 1.normal 2.decreased 3.absent Upper hepatic border:Right Midclavicular Line _Intercosta Shift dullness:1.negative 2.positive Ascites:_degree Pain on percussion in costovertebral area: 1.negative 2.positve _ Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis 4.absence
29、Gurgling sound:1.no 2.yes Vascular bruit 1.no 2.yes (location_)Genital organ: 1.unexamined 2.normal 3.abnormal Anus and rectum: 1.unexamined 2.normal 3.abnormalSpine and extremities: Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis) 3.Tenderness(location_) Extremities: 1.normal 2.arthremia & arthrocele (location_) 3.Ankylosis (location_) 4.Aropachy: 1.no 2.yes 5.Muscular atrophy (location_)Neurological system:1.normal 2.abnormal_ _Important examination results before hospitalized_