入院记录-新版

内科入院记录姓名性别年龄民族婚姻状况职业出生地入院时间MERGEFIELD80801US75G000002014年01月12日08:10:12记录时间MERGEFIELD80801US75G026002014年01月12日08:10:12病史陈述者MERGEFIELD80801US75G03F00[本人]主诉：主诉是指促使患者就诊的主要症状（或体征）及持续时间。MERGEFIELD80801US75G06Q00心慌，胸闷，头晕，口苦，上腹部不适十10多天现病史：是指患者本次疾病的发生、演变、诊疗等方面的详细情况，应当按时间顺序书写。内容包括发病情况、主要症状特点及其发展变化情况、伴随症状、发病后诊疗经过及结果、睡眠和饮食等一般情况的变化，以及与鉴别诊断有关的阳性或阴性资料等。1.发病情况：记录发病的时间、地点、起病缓急、前驱症状、可能的原因或诱因。2.主要症状特点及其发展变化情况：按发生的先后顺序描述主要症状的部位、性质、持续时间、程度、缓解或加剧因素，以及演变发展情况。3.伴随症状：记录伴随症状，描述伴随症状与主要症状之间的相互关系。4.发病以来诊治经过及结果：记录患者发病后到入院前，在院内、外接受检查与治疗的详细经过及效果。对患者提供的药名、诊断和手术名称需加引号（“”）以示区别。5.发病以来一般情况：简要记录患者发病后的精神状态、睡眠、食欲、大小便、体重等情况。与本次疾病虽无紧密关系、但仍需治疗的其他疾病情况，可在现病史后另起一段予以记录。MERGEFIELD80801US75G07300患者10天前因受凉及生气后出现心慌，胸闷，头晕时无耳鸣视物旋转，乏力，口苦，上腹部不适，叹气，夜间休息尚可，饮食尚可，二便正常；今日前来我院就诊，拟“胆囊炎，冠心病”收住，病程中无发热盗汗。既往史是指患者过去的健康和疾病情况。内容包括既往一般健康状况、疾病史、传染病史、预防接种史、手术外伤史、输血史、食物或药物过敏史等。既往史：平常健康状况：MERGEFIELD80801US75G08U00一般疾病史：MERGEFIELD80801US75G0AE00有：高血压6年，冠心病1年。传染病史：MERGEFIELD80801US75G0D800无预防接种史：MERGEFIELD80801US75G0EH00无预防接种药品MERGEFIELD80801US75G0IL00/手术外伤史：手术：MERGEFIELD80801US75G0LF00无外伤：MERGEFIELD80801US75G0NG00无输血史：MERGEFIELD80801US75G0PM00无输血反应：MERGEFIELD80801US75G0R100无药物过敏史：MERGEFIELD80801US75G0T100无过敏药物名称：MERGEFIELD80801US75G0UR00/个人史：经常居留地MERGEFIELD80801US75G13000固镇寄生虫疫水接触史MERGEFIELD80801US75G16600无吸烟史：MERGEFIELD80801US75G18201无戒烟：MERGEFIELD80801US75G1AM01/饮酒史：MERGEFIELD80801US75G1C901无戒酒：MERGEFIELD80801US75G1F101/其他MERGEFIELD80801US75G1G201/婚育史：结婚年龄MERGEFIELD80801US75G1ZB0119岁妊娠MERGEFIELD80801US75G1PA014次足月产MERGEFIELD80801US75G1Q9014次流产MERGEFIELD80801US75G1RI010次早产MERGEFIELD80801US75G1SD010次配偶健康状况：MERGEFIELD80801US75G1UA01健康其他MERGEFIELD80801US75G1VT01/月经史：初潮年龄MERGEFIELD80801US75G2170117岁经期MERGEFIELD80801US75G222017天周期MERGEFIELD80801US75G25P0128天末次月经MERGEFIELD80801US75G26L012014年01月05日绝经时间MERGEFIELD80801US75G27U01/其他MERGEFIELD80801US79A16C00/家族史：MERGEFIELD80800D56H11I002无内科入院记录（二）姓名MERGEFIELD80801US79A1FT00赵素娥科别MERGEFIELD80801US79A1H000内科病区MERGEFIELD80801US79A1I000内科床号MERGEFIELD80801US79A1J10003住院号MERGEFIELD80801US79A1LU001402303体格检查TMERGEFIELD80801US79A1ZM0036.2℃PMERGEFIELD80801US79A1PJ0065次/分RMERGEFIELD80801US79A1QP0019次/分BPMERGEFIELD80801US79A1RE00160/MERGEFIELD80801US79A1RU00100mmHg（kPa）一般情况：发育：MERGEFIELD80801US79A20M00正常营养：MERGEFIELD80801US79A22800中等面容：MERGEFIELD80801US79A26M00慢性病容表情：MERGEFIELD80801US79A2AV00淡漠体位：MERGEFIELD80801US79A2C900自动体位神智：MERGEFIELD80801US79A2EF00清楚配合检查：MERGEFIELD80801US79A2JJ00合作其他MERGEFIELD80801US79A2KK00/皮肤黏膜：色泽：MERGEFIELD80801US79A2MQ00正常皮疹：MERGEFIELD80801US79A2P900无皮下出血：MERGEFIELD80801US79A2RD00无毛发分布：MERGEFIELD80801US79A2T200正常皮肤温度：MERGEFIELD80801US79A2UQ00正常皮肤弹性：MERGEFIELD80801US79A30T00正常水肿：MERGEFIELD80801US79A33I00无肝掌：MERGEFIELD80801US79A35C00无蜘蛛痣：MERGEFIELD80801US79A36I00无其他MERGEFIELD80801US79A37K01/淋巴结：浅表淋巴结肿大：MERGEFIELD80801US79A3B101无头部：头颅大小：MERGEFIELD80801US79B01U01正常畸形：MERGEFIELD80801US79B03501无其他MERGEFIELD80801US7QG2DQ00/眼：眼睑：MERGEFIELD80801US79B05I01正常结膜：MERGEFIELD80801US79B07001正常巩膜黄染：MERGEFIELD80801US79B0C501无角膜：MERGEFIELD80801US79B0DJ01正常瞳孔：MERGEFIELD80801US79B0KZ01等大等圆瞳孔对光反射：MERGEFIELD80801US79B0NK01正常其他MERGEFIELD80801US79B0PN01/耳：耳廓：MERGEFIELD80801US79B11V01正常外耳道异常分泌物：MERGEFIELD80801US79B14301无乳突出压痛：MERGEFIELD80801US79B17Z01无听力障碍：MERGEFIELD80801US79B19501无其他MERGEFIELD80801US79B1AL01/鼻：鼻翼扇动：MERGEFIELD80801US79B1DE01无异常分泌物：MERGEFIELD80801US79B1FA01无鼻窦压痛：MERGEFIELD80801US79B1HZ01无口腔：唇：MERGEFIELD80801US79B1QQ01异常：紫绀粘膜：MERGEFIELD80801US79B1S601正常舌：MERGEFIELD80801US79B1U901正常齿：MERGEFIELD80801US79B1VD01正常扁桃体：MERGEFIELD80801US79B21L01正常咽：MERGEFIELD80801US79B22S01异常：充血其他MERGEFIELD80801US79B24F01/内科入院记录（三）姓名MERGEFIELD80801US7A90RC00赵素娥科别MERGEFIELD80801US7A90S400内科病区MERGEFIELD80801US7A90SU00内科床号MERGEFIELD80801US7A90U00003住院号MERGEFIELD80801US7A90UQ001402303颈部：颈项强直：MERGEFIELD80801US7A912100无颈静脉：MERGEFIELD80801US7A913200正常颈静脉回流征：MERGEFIELD80801US7A915900阴性气管：MERGEFIELD80801US7A917600居中甲状腺：MERGEFIELD80801US7A919600正常胸部：胸部：MERGEFIELD80801US7A91BQ00正常胸骨压痛：MERGEFIELD80801US7A91FP00无乳房：MERGEFIELD80801US7A91HB00正常其他MERGEFIELD80801US7A91IM00/肺：视诊：呼吸运动：MERGEFIELD80801US7A91P000正常触诊：语颤：MERGEFIELD80801US7A91RG00正常胸膜摩擦感：MERGEFIELD80801US7A91T400无叩诊：MERGEFIELD80801US7A922800正常清音听诊：呼吸音：MERGEFIELD80801US7A926Z00异常：粗啰音：MERGEFIELD80801US7A928U00无语音传导：MERGEFIELD80801US7A92AV00正常胸膜摩擦音：MERGEFIELD80801US7A92E800无其他MERGEFIELD80801US7A92FI00/心：视诊：心尖搏动：MERGEFIELD80801US7A92L600正常剑突下搏动：MERGEFIELD80801US7A92PB00无心尖搏动位置：MERGEFIELD80801US7A931J00正常触诊：心尖搏动：MERGEFIELD80801US7A935V00正常震颤：MERGEFIELD80801US7A93B100无叩诊：心脏相对浊音界：MERGEFIELD80801US7A93E700正常右（cm）肋间左（cm）MERGEFIELD80801US7AA06J01/ⅠMERGEFIELD80801US7AA08501/MERGEFIELD80801US7AA076012ⅡMERGEFIELD80801US7AA08C013.5MERGEFIELD80801US7AA07F013ⅢMERGEFIELD80801US7AA08K014MERGEFIELD80801US7AA07M013ⅣMERGEFIELD80801US7AA08Q016MERGEFIELD80801US7AA07U01/ⅤMERGEFIELD80801US7AA090019（前正中线距锁骨中线MERGEFIELD80801US7AA0CP019cm）听诊：心率MERGEFIELD80801US7AA0RD0165次/分心律：MERGEFIELD80801US7AA0T801整齐心音：MERGEFIELD80801US7AA12401异常：低P2MERGEFIELD80801US7AF3AH00<A2附加心音：MERGEFIELD80801US7AA19U01无杂音：MERGEFIELD80801US7AA1D101无心包摩擦音：MERGEFIELD80801US7AA1K601无其他MERGEFIELD80801US7AA1LK01/周围血管征：MERGEFIELD80801US7AA1Z101无内科入院记录（四）姓名MERGEFIELD80801US7AD09E00赵素娥科别MERGEFIELD80801US7AD0AQ00内科病区MERGEFIELD80801US7AD0BH00内科床号MERGEFIELD80801US7AD0C40003住院号MERGEFIELD80801US7AD0CR001402303腹部：视诊：外形：MERGEFIELD80801US7AD0GD00正常胃型：MERGEFIELD80801US7AD0HP00无肠型：MERGEFIELD80801US7AD0J200无腹壁静脉曲张：MERGEFIELD80801US7AD0K600无手术瘢痕：MERGEFIELD80801US7AD0LQ00无触诊：MERGEFIELD80801US7AD0N400全腹柔软压痛：MERGEFIELD80801US7AD0PM00无反跳痛：MERGEFIELD80801US7AD0RE00无腹部包块：MERGEFIELD80801US7AD0TV00无肝脏：MERGEFIELD80801US7AD13000未触及胆囊：MERGEFIELD80801US7AD1A800未触及Murphy征：MERGEFIELD80801US7AD1C700阴性脾脏：MERGEFIELD80801US7AD1DV00未触及肾脏：MERGEFIELD80801US7AD1FI00未触及叩诊：肝浊音界：MERGEFIELD80801US7AD1I400存在肝上界位于右锁骨中线MERGEFIELD80801US7AD1KG005肋间叩痛：MERGEFIELD80801US7AD1PL00无移动性浊音：MERGEFIELD80801US7AD1QK00阴性听诊：肠鸣音：MERGEFIELD80801US7AD1UN00正常气过水声：MERGEFIELD80801US7AD20300无其他：MERGEFIELD80801US7AD22100/直肠肛门：MERGEFIELD80801US7AD24H00未查外生殖器：MERGEFIELD80801US7AD26N00未查脊柱：MERGEFIELD80801US7AD27T00正常四肢：MERGEFIELD80801US7AD29G01正常其他MERGEFIELD80801US7AD2AK01/神经系统：MERGEFIELD80801US7AD2CT01生理反射存在，病理反射未引出辅助检查门诊及院外重要辅助检查结果（包括检查项目、医疗机构名称、日期、结果）MERGEFIELD80801US7AD2H701辅助检查：彩超：脂肪肝，胆囊壁欠光滑2014-1-10本院。心电图：窦性心律，ST轻度变化2014-1-12本院。内科入院记录（五）姓名MERGEFIELD80801US7AD2KD01赵素娥科别MERGEFIELD80801US7AD2LR01内科病区MERGEFIELD80801US