为了正常的体验网站,请在浏览器设置里面开启Javascript功能!

Anorectal medical record template(肛肠科病历模板)

2017-09-17 9页 doc 33KB 28阅读

用户头像

is_321575

暂无简介

举报
Anorectal medical record template(肛肠科病历模板)Anorectal medical record template(肛肠科病历模板) Anorectal medical record template(肛肠科病历模板) Complained of perianal swelling and pain for 2 days History: 2 days before admission due to private patients, no obvious cause was found around the anus swelling, pain refused t...
Anorectal medical record template(肛肠科病历模板)
Anorectal medical record template(肛肠科病历模板) Anorectal medical record template(肛肠科病历模板) Complained of perianal swelling and pain for 2 days History: 2 days before admission due to private patients, no obvious cause was found around the anus swelling, pain refused to press, no ulceration pus, no itching, no bleeding, no difficult defecation, nausea and vomiting, abdominal pain, diarrhea, cold fearless fever, without frequent micturition, urgency, dysuria and dysuria. Untreated. In today's visit to the hospital, the outpatient examination initially intended for "perianal abscess", undergraduate. Chen anal abscess pain refused to press, no ulceration pus, no skin itching, since admission, spirit, sleep, diet, urine can, no significant change in body weight. Past history: "hepatitis, tuberculosis, typhoid and deny the" history of infectious diseases, denied hypertension, diabetes and other genetic disease, trauma surgery and blood transfusion history, denied drug history of food allergy, vaccination history is unknown. Personal history: born in the country of origin, no "water" contact history and long-term foreign history of living, living and working conditions in general, no toxic and radioactive substances contact history. Smokeless wine and other bad habits. Obstetrical history: no special. Family history: deny other members of the family have similar medical history, deny the "hypertension, diabetes" and other familial genetic, infectious diseases history. physical examination T:36.2 P:82 R:20 BP125/75mmHg C / min / min Sane, normal development, nutrient medium, acute pain had entered the ward, automatic position, check the answer to the question, cooperation. The whole body skin mucous membrane has no yellow stain, no bleeding point, no liver palm, spider nevus. Superficial lymph nodes are not enlarged. The head has no deformity, the features are regular, the bilateral pupils are round and round, sensitive to light, no secretions in the external auditory canal, normal hearing and no tenderness of the mastoid. No paranasal sinus septum deviation, no tenderness, no lip pale gums, no swelling, no tongue centered, pharyngeal hyperemia, double tonsil enlargement. The neck soft, jugular vein without anger, the trachea in the center, no abnormal pulse of the carotid artery. Thorax symmetry, smooth breathing, tactile fremitus symmetry, percussion voiceless sound, breathing without clear and dry and wet rales. No uplift before the heart, apex is located on the left side of the V intercostal midclavicular line 0.5cm, did not touch the tremor, heart expand, heart rate 82 beats / min, the law is neat, area of each valve auscultation without pathological murmur. The abdomen is flat, the veins of the abdominal wall are not varicose, and there is no gastrointestinal or peristaltic wave. The abdomen, abdominal soft, complete abdomen tenderness, without bounce painful, and rib untouched, Murphy's sign. The upper liver is located in the right clavicle line, the fifth intercostal space, the liver and kidney area without percussion pain, and the moving voiced negative. Sounds 3 to 5 beats per minute, and at the end of succussion and vascular murmur. The anus sees the surgery condition, the spinal column, the four limbs moves freely. Surgical condition; the left side of the anus sees a part of swelling area, about 5X7cm in size, hard in quality, bright in surface, clear in boundaries, obvious in tenderness, and refuse to press. No obvious abnormalities were observed. Auxiliary examination: biochemical complete set: blood sugar: 14.6mmol/l. Blood routine + blood coagulation two: WBC:14.8X10^9/L, N:75.7%, but no obvious abnormalities. Urine glucose + 2 + 2 +, ketone, protein. Preliminary diagnosis: Anal Zhou Nongzhong Resident physician: Attending doctor: Chief physician: Complained of perianal swelling and pain for 2 days History: 2 days before admission due to private patients, no obvious cause was found around the anus swelling, pain refused to press, no ulceration pus, no itching, no bleeding, no difficult defecation, nausea and vomiting, abdominal pain, diarrhea, cold fearless fever, without frequent micturition, urgency, dysuria and dysuria. Untreated. In today's visit to the hospital, the outpatient examination initially intended for "perianal abscess", undergraduate. Chen anal abscess pain refused to press, no ulceration pus, no skin itching, since admission, spirit, sleep, diet, urine can, no significant change in body weight. Past history: "hepatitis, tuberculosis, typhoid and deny the" history of infectious diseases, denied hypertension, diabetes and other genetic disease, trauma surgery and blood transfusion history, denied drug history of food allergy, vaccination history is unknown. Personal history: born in the country of origin, no "water" contact history and long-term foreign history of living, living and working conditions in general, no toxic and radioactive substances contact history. Smokeless wine and other bad habits. Obstetrical history: no special. Family history: deny other members of the family have similar medical history, deny the "hypertension, diabetes" and other familial genetic, infectious diseases history. physical examination T:36.2 P:82 R:20 BP125/75mmHg C / min / min Sane, normal development, nutrient medium, acute pain had entered the ward, automatic position, check the answer to the question, cooperation. The whole body skin mucous membrane has no yellow stain, no bleeding point, no liver palm, spider nevus. Superficial lymph nodes are not enlarged. The head has no deformity, the features are regular, the bilateral pupils are round and round, sensitive to light, no secretions in the external auditory canal, normal hearing and no tenderness of the mastoid. No paranasal sinus septum deviation, no tenderness, no lip pale gums, no swelling, no tongue centered, pharyngeal hyperemia, double tonsil enlargement. The neck soft, jugular vein without anger, the trachea in the center, no abnormal pulse of the carotid artery. Thorax symmetry, smooth breathing, tactile fremitus symmetry, percussion voiceless sound, breathing without clear and dry and wet rales. No uplift before the heart, apex is located on the left side of the V intercostal midclavicular line 0.5cm, did not touch the tremor, heart expand, heart rate 82 beats / min, the law is neat, area of each valve auscultation without pathological murmur. The abdomen is flat, the veins of the abdominal wall are not varicose, and there is no gastrointestinal or peristaltic wave. The abdomen, abdominal soft, complete abdomen tenderness, without bounce painful, and rib untouched, Murphy's sign. The upper liver is located in the right clavicle line, the fifth intercostal space, the liver and kidney area without percussion pain, and the moving voiced negative. Sounds 3 to 5 beats per minute, and at the end of succussion and vascular murmur. The anus sees the surgery condition, the spinal column, the four limbs moves freely. Surgical condition; the left side of the anus sees a part of swelling area, about 5X7cm in size, hard in quality, bright in surface, clear in boundaries, obvious in tenderness, and refuse to press. No obvious abnormalities were observed. Auxiliary examination: biochemical complete set: blood sugar: 14.6mmol/l. Blood routine + blood coagulation two: WBC:14.8X10^9/L, N:75.7%, but no obvious abnormalities. Urine glucose + 2 + 2 +, ketone, protein. Preliminary diagnosis: Anal Zhou Nongzhong Resident physician: Attending doctor: Chief physician: Chief complaint: intermittent hematochezia, anal pain for 2 years History: 2 years ago due to patients with dry stool, defecation hard earned, blood in the stool, the quantity is little, the bright red color, such as anal pain, pain tear, no anal tumor prolapse, fearless cold fever, the self serving "herbal tea" the number of days after the symptoms disappear. Each because of eating spicy food or fatigue after the blood in the stool, anal pain, anal pain sometimes intermittent attacks, need 2 - 3 hours to ease, often visit the local medical station, diagnosed as "anal fissure", "oral anti-inflammatory, analgesic and hemostatic drugs", specific drugs is unknown and topical "Mayinglong Musk Hemorrhoids Ointment after treatment, can alleviate the symptoms, but no cure, so today in our hospital outpatient clinic required surgical treatment," pseudo anal fissure "admitted. Chen patients with hematochezia, less, color red, dry stool, anus pain, urination unobstructed, nake, sleep. Past history: "hepatitis, tuberculosis, typhoid and deny the" history of infectious diseases, denied hypertension, diabetes and other genetic disease, trauma surgery and blood transfusion history, denied drug history of food allergy, vaccination history is unknown. Personal history: born in the country of origin, no "water" contact history and long-term foreign history of living, living and working conditions in general, no toxic and radioactive substances contact history. Addicted to spicy food, no smoking or alcohol abuse. Obstetrical history: 28 years of marriage, not birth. Family history: deny other members of the family have similar medical history, deny the "hypertension, diabetes" and other familial genetic, infectious diseases history. Physical examination T36.6 P76 R20 BP130/70mmHg C / min / min Sane, normal development, nutrient medium, automatic position, subject cooperation, clear voice. All skin and mucous membranes were yellow free and superficial lymph nodes were not palpable. There is no deformity of the head, large circles of both sides of the eye, and sensitive to light. No lips cyanosis, red tongue, yellow and greasy fur, pulse string number. Neck soft, without swelling of the thyroid gland. Thorax symmetry, lungs are clear, and at the end of the dry and wet rales, heart rate of 76 beats per minute, the law is neat, area of each valve auscultation without pathological murmur. The abdomen is soft, no tenderness and rebound tenderness, subcostal liver and spleen not palpable, bowel sounds 5 times / min. There is no deformity of the spine and limbs, and there is no edema in both lower extremities. Anus circumstance sees specialist examination, external genital organs does not see unusual. Neurologic examination: bilateral and knee jerk reflexes were normal, Babinski sign negative, and Hoffman negative. Specialist examination: visual examination: 12 points of the anus, along the skin fold, there is a shuttle shaped cleft, about 1 cm long, base color red, edge thickening, cleft the lower edge of a peanut size about the knot hoof formation. Finger examination: not checked. Mirror examination: not checked. Supplementary Examination: Routine blood test: WBC:7.7 * 10^9/L, HB:140g/L, PLT:181 * 10^9/L, N:70.1%, L:23.1%. Urine routine: PH:5.0, urine bile: 0.2EU/DL. Preliminary diagnosis: Chinese medicine diagnosis: anal fissure Damp heat betting Western medical diagnosis: old anal fissure Resident physician: Admission diagnosis: Chinese medicine diagnosis: anal fissure Damp heat betting Western medical diagnosis: old anal fissure Attending doctor: 2010.02.04
/
本文档为【Anorectal medical record template(肛肠科病历模板)】,请使用软件OFFICE或WPS软件打开。作品中的文字与图均可以修改和编辑, 图片更改请在作品中右键图片并更换,文字修改请直接点击文字进行修改,也可以新增和删除文档中的内容。
[版权声明] 本站所有资料为用户分享产生,若发现您的权利被侵害,请联系客服邮件isharekefu@iask.cn,我们尽快处理。 本作品所展示的图片、画像、字体、音乐的版权可能需版权方额外授权,请谨慎使用。 网站提供的党政主题相关内容(国旗、国徽、党徽..)目的在于配合国家政策宣传,仅限个人学习分享使用,禁止用于任何广告和商用目的。

历史搜索

    清空历史搜索