住院病历写作范本

1、住院病歷寫作範本行政院國軍退除役官兵輔導委員會高雄榮民總醫院Veterans General Hospital-Kaohsiung一般外科住院病歷範本 NAME:AGE: years old SEX: Male / FemaleMARITAL STATUS: married/single/divorced/separatedDATE OF ADMISSION: HOSPITAL NUMBER: OCCUPATION:CHIEF COMPLAINT:Symptom + Duration (or since when) in one sentence例: RUQ pain and fever fo

2、r 3 days PRESENT ILLNESS: 內容須包含1. Related past illnesses & previous hospitalizations2. The process of illness3. ER (including other hospital): Presentation, Lab findings, Management4. Throughout the whole course of the present illness例: According to the statement of patient herself, she had hist

3、ory suggestive of chronic cholecystitis with periodic indigestion, flatulence and epigastric distress sometimes accompanied by mild fever and transient jaundice. Her recurrent gallstone colic often precipitated by dietary indiscrimination principally overate fatty foods or eggs with agonizingly righ

4、t upper quadrant pain usually lasted several minutes sometimes referred to the homolateral infraclavicular region accompanied by vomiting and prostration. Three days ago, a sharp, knife-like pain burst abruptly in the right hypochondriac region about one hour after adventitious indulged in fried rou

5、gh food. The colic lasted some 20 minutes and vanished naturally then relapsed three times, intensifying in severity and once radiated to the infrascapular area upward. She was admitted to LMD and received series of blood tests and radiological examination. With the impression of chronic cholecystit

6、is with acute exacerbation, she received IV fluid supplement and pain control and her symptoms subsided. She was discharge after a two-day hospitalization. Unfortunately, the RUQ pain attacked again three hours prior to this admission. She visited our Emergency Department for help. Physical examinat

7、ions revealed RUQ tenderness and positive Murphys sign. Laboratory findings revealed leuokocytosis and slightly elevated liver enzymes. Total bilirubin was within normal limit. Sonography disclosed multiple gallstones, distended gallbladder and wall thickening. The common bile duct and intrahepatic

8、duct were not dilated. There was no sign suggested of pancreatitis. Under the impression of gallstones with acute cholecystitis, she was admitted for urgent cholecystectomyThroughout the whole course of present illness, there were fever, nausea, vomiting and abdominal fullness. There was no jaundice

9、, chill, She is a typical subject of high dangerous group of gallstone with contributing factors of five F known as Female, Fertile, Fat, Fasting, and the age of Forty PAST HISTORY: (若無重要疾病之病史請註明)1. Denied history of DM / under control with OHA , NPH 用藥、追蹤院所、固定不固定 2. Denied history of hypertension /

10、 regular / irregular medical control with Doxaben , Norvac etc 用藥、追蹤院所、固定不固定3. or other cardiovascular disorders / CAD with TVD , DVD , s/p PTCA用藥、追蹤院所、固定不固定4. Denied history of pulmonary TB, COPD or other pulmonary diseases5. Denied history of liver diseases. / Child 6. Denied history of surgery Pr

11、evious operations: 診斷、手術名稱及手術日期、院所PERSONAL HISTORY:1. Denied history of smoking : nil/1 pack/day for 20 years2. Denied history of alcohol drinking3. Denied history of allergy to food or drugsFAMILY HISTORY : Non-contributory PHYSICAL EXAMINATIONS:GENERAL:Well-/ Moderate / Poor nourished and normal-d

12、eveloped adultNo skin yellowish discoloration.HEENT:No DeformityNo Pale Conjunctiva.No Icteric ScleraNECK:No StiffnessNo Limitation of Movement.No Palpable LN. No Carotid Bruit.No Jugular Vein Engorgement.CHEST and HEART:Symmetrical and Full Expansion of Bilateral Chest Wall. No Wheezing.No Rales.No

13、 Cardiac MurmurNo Cardiac Arrhythmia., irregular HRABDOMEN:Local Tenderness over RUQ of abdomenNo Rebounding Pain No Muscle Guarding.Positive /negativeMurphys Sign (+)No Hepatomegaly.No Palpable MassNo Shifting Dullness.Normoactive Bowel Sound:BACK :No deformityNo CV Angle Knocking Pain.EXTREMITY :N

14、o Limitation of Movement.No Deformity.No Peripheral Cyanosis. No Clubbing Finger.No Pitting Edema.DIGITAL EXAM :Prostate: Smooth, rubbery, no hard nodule, size: 3x3cm Normal anal tone, no rectal shelf ,no hemorrhoid/internal , external hemorrhoid NEUROLOGICAL EXAM : Cranial nerve : intact DTR : syme

15、tric 2+Babinski sign : negativeMuscle power : symetric 5 score Muscle power DTREXOGENITALIA:No penile lesionNo scrotal swelling, Testis (size, tenderness, masses, varicocele)Laboratory Findings: (檢驗值單位要寫)Blood Routine: Hgb 14.5gm%, RBC: 3.93m/cumm, WBC: 12400/cumm, Hematocrit: 45%Differential count:

16、 Neutrophil 82%, lymphocyte 15%, monocyte 3%, basophile 0%, eosinophil 0%Liver function test: T.bil. 1.3 mg/dl, GOT: 54 U/ml, GPT: 62 U/ml, Alk-P: 97 U/ml, rGT: 74 U/ml, Amylase: 127 U/mlGS CONDITION:內容須包含1. Clinical symptom (例如 abdominal pain; icteric sclera, fever, radiation pain to shoulder, atta

17、ck related before/after/not related to meal等有關的症狀)2. Physical examination (ex: palpable gallbladder, Murphys sign)3. ER finding (包括各種影像學檢查, 例如 KUB ,Sono of abdomen, abdominal CT scan)4. 外院相關資料5. 相關past history 或family history例:Epigastric and RUQ pain, exacerbated by fatty meal, no radiation to backL

18、ocal tenderness over RUQ region with obvious Murphys sign Sonography of abdomen: Multiple gallstones with gallbladder distension, wall thicknessIMPRESSION:Gallstones with acute cholecystitis PLANS TO DO:1. Admission routine2. Preoperative preparation3. Urgent laparoscopic cholecystectomy _/ R <Pr

19、e-operative Note>Indication for surgery1. Positive physical finding: RUQ of abdomen tenderness and positive Murphys sign2. Positive laboratory finding: Blood routine WBC 12400/cumm Neutrophil 82%, lymphocyte 15%3. Positive image finding: Sonography of abdomen showed gallbladder distention and wal

20、l thickeningIntended surgical procedure:Laparoscopic cholecystectomyThe surgical procedure and risks have been well-explained to patient and patients family_/ R <Post-operative Note>Operative finding:Two pigmented gallstones were impacted over cystic duct with white bile, cystic duct 0.3 cm in

21、 diameterNo livercirrhosis, no ascitesOne J-p drain was placed over Morrisons pouchBlood loss: 30 ml, no blood inOperative procedure: Laparoscopic cholecystectomyPossible immediate post-operative complications:Bile leakage; internal bleeding_/ R <Progress Note>Post-OP Day 1S: Wound painO: Conscious clear Vital sign BP: 140/80 mmHg, PR 90 1/min, RR 20 1/min BT: 37.5Coarse breathing sound, whitish sputum Wound: clear J-P drain: serosanguinous fluid, 20 ml NG free drain: 100ml, bilous fluidA: Acute cholecystitis s/p laparoscopic chole