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    2-醫學四-住院病歷寫作範本 - 原則 增修版

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    蘇西瓦
    This document provides a reference template for writing internal medicine discharge summaries at Longjing Medical Hospital. It outlines the sections that should be included such as chief complaint, present illness, past medical history, personal history, family history, physical examination, laboratory findings, impression, and plans. Key details are provided for each section, such as only including 2 symptoms for chief complaint and presenting problems in a systematic timeline. The physical exam section should quantify any positive findings. The impression section should list diagnoses by importance with the active problem first. The plans section should include diagnostic and treatment plans for each impression along with the rationale.

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    2-醫學四-住院病歷寫作範本 - 原則 增修版

    Uploaded by

    蘇西瓦
    1K views6 pages
    This document provides a reference template for writing internal medicine discharge summaries at Longjing Medical Hospital. It outlines the sections that should be included such as chief complaint, present illness, past medical history, personal history, family history, physical examination, laboratory findings, impression, and plans. Key details are provided for each section, such as only including 2 symptoms for chief complaint and presenting problems in a systematic timeline. The physical exam section should quantify any positive findings. The impression section should list diagnoses by importance with the active problem first. The plans section should include diagnostic and treatment plans for each impression along with the rationale.

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    2-醫學四-住院病歷寫作範本_原則 增修版

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    This document provides a reference template for writing internal medicine discharge summaries at Longjing Medical Hospital. It outlines the sections that should be included such as chief complaint, present illness, past medical history, personal history, family history, physical examination, laboratory findings, impression, and plans. Key details are provided for each section, such as only including 2 symptoms for chief complaint and presenting problems in a systematic timeline. The physical exam section should quantify any positive findings. The impression section should list diagnoses by importance with the active problem first. The plans section should include diagnostic and treatment plans for each impression along with the rationale.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    1K views6 pages

    2-醫學四-住院病歷寫作範本 - 原則 增修版

    Uploaded by

    蘇西瓦
    This document provides a reference template for writing internal medicine discharge summaries at Longjing Medical Hospital. It outlines the sections that should be included such as chief complaint, present illness, past medical history, personal history, family history, physical examination, laboratory findings, impression, and plans. Key details are provided for each section, such as only including 2 symptoms for chief complaint and presenting problems in a systematic timeline. The physical exam section should quantify any positive findings. The impression section should list diagnoses by importance with the active problem first. The plans section should include diagnostic and treatment plans for each impression along with the rationale.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 6

    : Dr.

    99/02/05

    :(General Data) : : Married or single or divorced : : (?) : : : According to patient himself or family (who?)

    CHIEF COMPLAINT:

    date

    : RUQ pain and fever for 3 days Chest tightness and palpitation since 6/10, 730pm (Bad example) Chest tightness and palpitation for 1 hour

    PRESENT ILLNESS:
    1.

    past illnesses & previous hospitalizations chief complaint

    2.

    (Your differential diagnosis) (negative findings)

    3.

    (Concurrent diseases) (Co-morbidity)

    : This 46-year-old woman has a history of diabetes mellitus and stroke with left-sided weakness, and has been taking medication for 10 years as doctors prescription. She has suffered from flatulence and epigastric distress sometimes accompanied by mild fever since January 23, 2007. Her distress was often precipitated by fatty foods or eggs with accompanying right upper quadrant pain lasting several minutes sometimes. The distress or pain could refer to the homolateral infraclavicular region accompanied by vomiting and prostration. Three days before entry to our ER, a sharp, knife-like pain burst abruptly in the right upper quadrant region about one hour after taking fried rough food. The colic lasted about 20 minutes and vanished spontaneously then relapsed twice with spiking fever, chills and radiation to the infrascapular area upward.

    She was admitted to a local hospital and received some blood tests and radiological examination. With the impression of acute cholecystitis, she received IV fluid supplement and pain control, but her symptoms were not relieved. She was then transferred to our ER as family requested. In our ER, physical examinations revealed RUQ tenderness with positive Murphys sign. Laboratory findings revealed leuokocytosis and slightly elevated liver enzymes (AST ?? U/L AlK-P ?? U/L). Total bilirubin was within normal limit. Sonography disclosed multiple gallstones, distended gallbladder and wall thickening. The common bile duct and intrahepatic duct were not dilated. Under the impression of gallstones with acute cholecystitis, she was admitted to GI ward for continuing the antibiotic treatment and observe if the progression will need surgical intervention.
    2

    Throughout the whole course of present illness, there were fever, nausea, vomiting and abdominal fullness, but no tea-colored urine.

    PAST HISTORY:
    1.

    DM / under control with OHA , NPH [ ]

    2.

    Hypertension / regular / irregular medical control with Doxaben , Norvac etc [ ] or other cardiovascular disorders / CAD with TVD , DVD , s/p PTCA[]

    3. 4. 5. 6.

    Denied history of pulmonary TB, COPD or other pulmonary diseases Denied history of liver diseases. / Child Denied history of surgery Previous operations: [] active inactive problems

    PERSONAL HISTORY:
    1. 2. 3.

    Denied history of smoking : nil/1 pack/day for 20 years Denied history of alcohol drinking Denied history of allergy to food or drugs

    FAMILY HISTORY : DO NOT USE Non-contributory, Nil or Nothing particular pedigree tree non-contributory
    3

    Review of System: Review of Systems (ROS)

    positive findings General Consciousness (Drowsy) E2V2M4 Drowsy positive finding Coma scale Dehydration (Yes) Dry tongue and poor skin turgor Dehydration Consciousness (+) or (-) !!

    PHYSICAL EXAMINATIONS: 1. 2. , Ex., Pitting edema (+) or (++), Gr. II/VI Pansystolic murmur over left lower sternal border with radiating to left axilla GENERAL: Well-/ Moderate / Poor nourished and normal-developed adult No skin yellowish discoloration. HEENT: No Deformity No Icteric Sclera
    4

    No Pale Conjunctiva.

    NECK: No Stiffness No Palpable LN. No Limitation of Movement. No Carotid Bruit.

    No Jugular Vein Engorgement. CHEST and HEART: Symmetrical and Full Expansion of Bilateral Chest Wall. No Wheezing. No Cardiac Murmur ABDOMEN: Local Tenderness over RUQ area of abdomen No Rebounding Pain No Muscle Guarding. No Rales. No Cardiac Arrhythmia., irregular HR

    Positive /negativeMurphys Sign (+) No Hepatomegaly. No Palpable Mass Normoactive Bowel Sound BACK : No deformity EXTREMITY : No Limitation of Movement. No Deformity. No Peripheral Cyanosis. No Pitting Edema. DIGITAL EXAM : Prostate: Smooth, rubbery, no hard nodule, size: 3x3cm Normal anal tone, no rectal shelf ,no hemorrhoid/internal , external hemorrhoid EXOGENITALIA: No genital lesion No Clubbing Finger. No CV Angle Knocking Pain. No Shifting Dullness.

    Laboratory Findings: ()
    5

    ( , Cultures, , KUB, Sonography of abdomen, abdominal CT scan) &

    IMPRESSION: active inactive problems etiological diagnosis anatomical diagnosis, symptomatic diagnosis

    Duodenal ulceranatomical diagnosis NSAID induced ulceretiological diagnosis Abdominal pain, caused to be determinedsymptomatic diagnosis

    PLANS ()

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