Tài liệu Bệnh án ngoại khoa

BỆNH ÁN NGOẠI KHOA I. PHẦN HÀNH CHÍNH 1. Họ và tên bệnh nhân ( in hoa ):................................................................................................. 2. Ngày, tháng, năm, sinh:............................................................................................................ 3. Giới: ...............................................................Dân tộc:............................................................ 4. Nghề nghiệp:............................................................................................................................ 5. Địa chỉ:..................................................................................................................................... 6. Nơi làm việc:............................................................................................................................ 7. Họ tên, địa chỉ người nhà khi cần báo tin:................................................................................ ...................................................................................................................................................... 8. Vào viện / khoa…………………….: lúc……giờ……phút – ngày ……./…..../……. 9. Nơi giới thiệu:  Cơ quan y tế:.....................................................................................................................  Cán bộ y tế: phòng khám y tế tư nhân, nhân viên y tế thôn bản:.......................................  Tự đến:  Khác, ghi rõ:...................................................................................................................... 10. Chẩn đoán nơi giới thiệu:....................................................................................................... ...................................................................................................................................................... II. LÝ DO VÀO VIỆN ......................................................................................................................................................  Vào ngày thứ …….của bệnh. III. BỆNH SỬ 1. Quá trình bệnh lý:.................................................................................................................. ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Trường CĐYT Lâm Đồng Trang 1 / 8 Bệnh án ngoại khoa.doc ...................................................................................................................................................... 2. Tình trạng hiện tại: bệnh nhân đang ở ngày thứ…….. của bệnh. ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... IV. TIỀN SỬ BỆNH 1. Bản thân:  Phát triển thể lực từ nhỏ đến lớn:.......................................................................................  Những bệnh đã mắc phải:.................................................................................................. ................................................................................................................................................ ................................................................................................................................................  Tiêm phòng:......................................................................................................................  Chế độ ăn uống, sinh hoạt:................................................................................................ ................................................................................................................................................  Dị ứng:............................................................................................................................... 2. Gia đình:  Những bệnh người thân trong gia đình ( bố, mẹ, anh, chị em,…) đã mắc:........................ ............................................................................................................................................... ...............................................................................................................................................  Đời sống tinh thần, vật chất:.............................................................................................. ........................................................................................................................................... V. KHÁM BỆNH 1. Toàn thân: ý thức, da niêm mạc, hệ thống hạch, tuyến giáp,… ...................................................................................................................................................... ......................................................................................................................................................  Mạch...................................lần/phút  Nhiệt....................................0C ......................................................................................................................................................  Huyết áp………../……….. mmHg ......................................................................................................................................................  Nhịp thở..............................lần/phút ......................................................................................................................................................  BMI .................................... ......................................................................................................................................................  Cân nặng.............................Kg ......................................................................................................................................................  Chiều cao............................m ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Trường CĐYT Lâm Đồng Trang 2 / 8 Bệnh án ngoại khoa.doc ...................................................................................................................................................... 2. Các cơ quan: 2.1. Tuần hoàn - tim mạch: ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.2. Hô hấp: ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.3. Tiêu hóa: ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.4. Thận – Tiết niệu – Sinh dục: ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.5. Thần kinh: ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.6. Cơ – Xương – Khớp: ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Trường CĐYT Lâm Đồng Trang 3 / 8 Bệnh án ngoại khoa.doc ...................................................................................................................................................... 2.7. Tai – Mũi – Họng:..................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.8. Răng – Hàm – Mặt:.................................................................................................. ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.9. Mắt:............................................................................................................................ ...................................................................................................................................................... ...................................................................................................................................................... 2.10. Nội tiết – Dinh dưỡng và các bệnh lý khác:.......................................................... ...................................................................................................................................................... ...................................................................................................................................................... VI. CHẨN ĐOÁN 1. Chẩn đoán sơ bộ:.................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2. Chẩn đoán phân biệt:............................................................................................................. ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 3. Bệnh kèm theo:....................................................................................................................... ...................................................................................................................................................... VII. BIỆN LUẬN ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Trường CĐYT Lâm Đồng Trang 4 / 8 Bệnh án ngoại khoa.doc ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... VIII. CẬN LÂM SÀNG ĐÃ CÓ ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... IX. CẬN LÂM SÀNG ĐỀ NGHỊ ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... X. KẾT QUẢ CẬN LÂM SÀNG 1. Công thức máu: Kết quả WBC ngày.............................................. Đơn vị tính K / uL Khoảng bình thường Kết luận 4.1 – 10.0 LYM 0.6 – 4.1 * MID 0.0 – 1.8 GRAN 2.0 – 7.8 RBC M / uL 4.20 – 6.30 HGB G / dL 12.0 – 18.0 HCT % 37.0 – 51.0 K / uL 140 – 440 PLT Trường CĐYT Lâm Đồng Trang 5 / 8 Bệnh án ngoại khoa.doc 2. X.Quang:………………………… ngày................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 3. Siêu âm: …………………………. ngày................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 4. Cận Lâm Sàng khác:……………. ngày................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... XI. TÓM TẮT BỆNH ÁN ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Trường CĐYT Lâm Đồng Trang 6 / 8 Bệnh án ngoại khoa.doc ...................................................................................................................................................... XII. CHẨN ĐOÁN XÁC ĐỊNH ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... XIII. TIÊN LƯỢNG............................................................................................................. XIV. DỰ HẬU ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... XV. ĐIỀU TRỊ 1. Hướng điều trị: 1.1 Hướng điều trị............................................................................................................ ........................................................................................................................................... 1.2 Chế độ điều trị........................................................................................................... 2. Điều trị: 2.1 Thuốc............................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2.1 Chế độ chăm sóc hỗ trợ.................................................................................................. ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Trường CĐYT Lâm Đồng Trang 7 / 8 Bệnh án ngoại khoa.doc ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... XVI.GIÁO DỤC SỨC KHỎE 1. Trong khi nằm viện................................................................................................................ ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 2. sau khi ra viện......................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Đà Lạt, ngày……tháng……năm…… Người làm bệnh án Trường CĐYT Lâm Đồng Trang 8 / 8 Bệnh án ngoại khoa.doc Họ và tên y sinh:......................................................................... Trường CĐYT Lâm Đồng Trang 9 / 8 Bệnh án ngoại khoa.doc