財團法人彰化基督教醫院
實習醫學生 General history
科別:
性別:
病歷號碼:
姓名:
病床號:
年齡:
一般資料(General Data) :
Date of admission:
Marital status:
Occupation:
Source of information:
Reliability of source:
Adverse drug reaction:
主訴(Chief Complaint):
現在病症(Present Illness):
過去病史(Past History):
Drugs history:
DM (-)
HTN (-)
Operation history :
個人病史(Personal History):
Smoking:
Alcohol:
Betel Nut:
Allergy:
Travel History:
Sexual History:
Special environmental exposures:
家族病史(Family History):
Not contributory
系統整理(REVIEW OF SYSTEM) :
General: Weight loss(-), fever(-), chills(-), anorexia(-), general malaise(-), drowsiness(-),Others
HEENT: Headache(-), diplopia(-), ptosis(-), facial swelling(-), facial flushing(-), Sorethroat(-),
mouth ulcers(-), hoarseness(-), rhinorrhea(-), neck mass(-), Others
Respiratory: Shortness of breath(-), exertional dyspnea(-), nocturnal dyspnea(-), paroxysmal
dyspnea(-), productive cough(-), nonproductive cough(-), night cough(-), purulent
sputum(-), rusty sputum(-), bronchorrhea(-), blood-tinged sputum(-), hemoptysis(-),
night sweating(-), chest pain(-), wheezing(-), Others
Cardiovascular: Palpitation(-), precordial oppression(-), syncope(-), ankle swelling(-), Orthopnea(-),
exertional dyspnea(-), chest pain(-), Others
Gastrointestinal: Epigastralgia(-), nausea(-), vomiting(-), melena(-), tarry stool(-), heartburn (-),
Acid regurgitation(-), dysphagia(-), diarrhea(-), change of bowel habits(-), jaundice(-),
abdominal fullness(-), Others
Hematological: Bone pain(-), easy bruising(-), fatigue(-), rash(-), Others
Genitourinary: Dysuria(-), frequency(-), urgency(-), hiccup(-), edema(-), hematuria(-), Others
Musculoskeletal: Joint pain(-), morning stiffness(-), joint swelling(-), Others
Neurological: Headache(-), dizziness(-), limb pain(-), numbness(-), slurred speech(-), stool
incontinence(-), urinary incontinence(-), ataxia(-), Others
Endocrine: Thirst(-), polyuria(-), polydipsia(-), Others
理學檢查( PHYSICAL EXAMINATION ):
1. General Appearance: A MN & MD male, acute ill-looking
Breathing pattern: no cardiorespiratory distress.
Conscious level: E4V5M6
2. Vital signs: BP: mmHg, PR: / min, RR: /min
BT =
℃
3. HEENT:
Head & Face: Deformities (-), surgical scars (-), receding chin (-)
Eyes: conjunctiva: pale (-), sclera:icteric: (-)
isocoric pupils, 3 mm/ 3 mm, with prompt light reflex, ou
Direct light reflex: +/+, Consensual light reflex: +/+
Ears: otorrhea (-), perichondritis (-)
Nose: nasal septum deviation (-)
Throat: red pharynx (-), tonsillar enlargement (-), oral thrush (-), oral ulcers (-)
4. Neck: supple(in lateral/A-P direction)
jugular venous engorgement (-), lymphadenopathy (-), Neck mass palpated (-)
strider (-), carotid bruit (-), bilateral, thyroid enlargement (-), goiter (-)
5. Chest & Lungs:
Inspection – symmetrical chest expansion,
no chest deformity ( barrel-shaped, pectus excavatum)
Auscultation - clear breathing sound, no Rales, rhonchi (-), wheezing (-)
Percussion: Dullness(-), hyperresonance(-)
Palpation: deformity (-)
6. Heart:
Inspection - PMI visible at 5th ICS
Auscultation - regular heart beat
S1, S2: normal
No S3 or S4
opening snap (-) midsystolic click (-) murmur (-)
Palpation: LV/RV heave (-), Thrill (-)
PMI is palpated over5th ICS
7. Abdomen:
Inspection - falp in shape, abdominal venous distention (-)
Auscultation - normoactive bowel sounds, abdominal bruit (-)
Percussion - shifting dullness (-), increased splenic dullness (-)
Palpation - tenderness (-), rebound tenderness (-), muscle guarding (-), knocking tenderness (-)
Liver edge is palpated 1 FB below right costal margin (RCM) Spleen palpated (-)
8. Extremities: freely movable, no pitting edema over bilateral lower legs,
inflammation or deformities over joints (-); finger cyanosis (-)
9. Back & Spines: Straight, scoliosis (-) or kyphosis (-)
CV angle knocking tenderness (-), knocking tenderness over spine (-), mass palpated (-).
10. Skin: normal skin turgor, rash (-), petechia (-) or ecchymoses (-), Hyperpigmentation (-),
depigmentation (-)
11. Neurological examination:
GCS: E4V5M6, Consciousness level: clear JOMAC: can't evaluate
CXR:
KUB:
[ 請練習手繪 CXR 及 KUB ]
一般檢查 (Laboratory DATA): [ 含以往之重要 data ]
[ 此部份可利用彰基 2000 Copy ]
暫時性診斷(Tentative Diagnosis):
1.
2.
處理計畫(Plan to do) :
1.
2. .
指導醫師 :
實習醫學生: [請 sign 名字]