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標準病歷格式

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最後更新時間:2018/10/12 17:53:16
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Chief Complaints:
Present Illness:
Past history:
1.Medical history:
2.Surgical history:
3.Admission history :
Personal history:
1.Smoking:
2.Drinking:

Drug history:
 
Allergy History:
1. No known allergy to injected or oral drugs
2. No known allergy to food or environment substance
Family History:
1. No known family history of hepatitis,hepatoma,colon Ca or other GI malignancy
2. No known family history of polyposis syndrome
3. Denied family history of DM, TB, Heart disease, Hypertension, renal disease, cancer, arthritis, anemia, headache, seizure, psycholigic problem
Review of Systems:
General: No body weight change, No fatigue, No fever, No chills, No anorexia, No
night sweating, No weakness, No insomnia, No irritability
Skin: No rashes, No itching, No bruising, No petechiae, No spider angiomata, No hair loss, No nail change
Head: No head trauma history, No headache
Eyes: No blurred vision, No photophobia, No diplopia, No red eye, No discharge, No eye pain
Ears: No hearing impairment, No tinnitus, No otalgia, No discharge
Nose: No epistaxis, No nasal obstruction, No rhinorrhea 
Throat and oral cavity: No gum bleeding, no hoarsening, no sore throat
Neck: No neck pain, No neck stiffness
Breast: No gynecomastia, No nipple discharge, No pain, no lump
Respiratory: No cough, No sputum, No hemoptysis, No wheezing, No stridor, No shortness of breath
Cardiovascular: No exertional chest pain, No DOE, No PND, No palpitation, No hypertension
Gastrointestinal: No dysphagia, No heart burn, No bloating, No belching, No flatulence, No nausea, No vomiting, No hematemesis, No tarry stool, No matochezia,No constipation, No diarrhea, No abdominal pain, No jaundice, No tea-color urine, No change of bowel habit, No dyspepsia, No borborygmus, No food intolerance.
Genitourinary: No polyuria, No nocturnal micturation, No urinary urgency, No post-micturation dripping, No urinary incontinence.
Endocrine: No cold intolerance, No heat intolerance, No tremor, No polyuria, No polydipsia, No polyphagia, Musculoskeletal.No joint pain, No myalgia, No stiffness of joint, No deformity of joint, No back pain, 
Hematology: No anemia, No easy bruising, No ecchymosis, No night sweating,
Neuropsychiatric: No syncope, No seizure, No fainting, No paralysis, No paresthesia, No tremor, No involuntary movement, No anxiety No emotional distress, No memory impairment, No auditary or visual halluciation, no consciousness.
Physical examination:
General appearance: 
Vital Signs and consciousness level:
a. BP mmHg b. PR /min ,c. RR /min, d. BT C. e. GCS:E V M 
Skin:
Warm and adequate skin turgor
No yellowish skin color, no rash, no purpura
Normal appearance, distribution and texture of skin, No palm erythema 
Lymph nodes:
No cervical, supraclavicular, axillary, inguinal, lymphadenopathy
HEENT:
Head:
 normocephalic and atraumatic; no lesions 
Eye: cornea without lesion
Conjunctiva is not palor
Sclera is not icteric
Pupil are equal, 3mm in size, round, reactive to light
EOM are normal, no nystagmus or strasbismus
Ears: normal in appearance; no obvious hearing loss
Nose: no nasal discharge, no deformity, no sinus tenderness
Mouth & throat: Lips wihthout cyanosis or pallor
Normal appearance of buccal mucosa
No injection in the throat 
Neck: Supple, No evidence of tracheal deviation, No jugular venous engorgement, no lymphadenopathy, Thyroid gland is normal in size and without palpable nodules
Chest:
Inspection: symmetric and full expansion, bil. normal AP diameter 
Palpation: No palpable nodule; no tenderness
Percussion: Resonant throughout
Auscultation: No rales, no wheezing, no rhonchi, No friction rub
Heart:
Inspection: invisible PMI
Palpation: No heaves or thrills
PMI is medial to the midclavicular line, 4th ICS
Percussion: dullness in character
Auscultation: RHB with systolic murmur Gr 2/6 LLSB
Normal S1, S2
No gallop, no extrasystoles, no friction rub
Abdomen:
Inspection: flat, no superfical venous engorgement
Auscultation: nomoactive bowel sound; no abdominal bruits
Percussion:Liver span is about 10cm RMCL, No shifting dullness, No knocking pain
Palpation:No palpable mass, No palpable spleen or liver, no abdominal tenderness
Digital Exam: No palpable mass, no tarry stool
Gential organ: No ulceration, no herniation
Extremities: No clubbing or cyansis, No pitting edema or varicose vein of bil. low legs, No joint deformities and full range of motion, No bone, joint, or muscle tenderness
Neurologic: Mental Status Exam: oriented to time, person, and place; normal 7 subtraction test
Motor: MP: all 5 points
Sensory:symmetric and response to pinprick
Impression 1:

Plan 1:
VS___________/R3 _____________