Tài liệu Bệnh án nội khoa

BỆNH ÁN NỘI 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 nội 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, chế độ ăn uống, sinh hoạt, … ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... 2. Gia đình: những bệnh người than trong gia đình ( bố, mẹ, anh chẹ em,…) đẵ mắc, đời sống vật chất, tinh thần,… ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... Trường CĐYT Lâm Đồng trang 2 / 8 Bệnh án nội khoa.doc 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 .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2. Các cơ quan: 2.1. Tuần hoàn - tim mạch: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.2. Hô hấp: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.3. Tiêu hóa: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. Trường CĐYT Lâm Đồng trang 3 / 8 Bệnh án nội khoa.doc .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.4. Thận – Tiết niệu – Sinh dục .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.5. Thần kinh: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.6. Cơ – Xương – Khớp:......................................................................................................... .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 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. CẬN LÂM SÀNG ĐỀ NGHỊ Trường CĐYT Lâm Đồng trang 4 / 8 Bệnh án nội khoa.doc .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. VII. KẾT QUẢ CẬN LÂM SÀNG 1. Công thức máu: Kết quả 2. ngày WBC ngày.............................................. Đơn vị tính K / uL Khoảng bình thường 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 Kết luận X.Quang: 2. X.Quang:………………………… ngày................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 3. Siêu âm: …………………………. ngày................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... 4. Cận Lâm Sàng khác:……………. ngày................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Trường CĐYT Lâm Đồng trang 5 / 8 Bệnh án nội khoa.doc VIII. TÓM TẮT BỆNH ÁN .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 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IX. CHẨN ĐOÁN 1. Chẩn đoán....................................................................................................................................... .............................................................................................................................................................. .............................................................................................................................................................. 2. Biện luận.......................................................................................................................................... .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. Trường CĐYT Lâm Đồng trang 6 / 8 Bệnh án nội khoa.doc .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 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.............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 3. Chẩn đoán phân biệt...................................................................................................................... .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 4. Bệnh kèm theo................................................................................................................................. .............................................................................................................................................................. X. TIÊN LƯỢNG........................................................................................................................... Trường CĐYT Lâm Đồng trang 7 / 8 Bệnh án nội khoa.doc XI. ĐIỀU TRỊ 1. Hướng điều trị:............................................................................................................................... .............................................................................................................................................................. 2. Thuốc điều trị:................................................................................................................................ .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. XII.GIÁO DỤC SỨC KHỎE 1. Trong khi nằm viện........................................................................................................................ .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2. Sau khi ra viện................................................................................................................................ .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. Đà Lạt, ngày……tháng……năm…… Người làm bệnh án Họ và tên y sinh:......................................................................... Trường CĐYT Lâm Đồng trang 8 / 8 Bệnh án nội khoa.doc