Tài liệu Bệnh án sản khoa

BỆNH ÁN SẢN KHOA I. PHẦN HÀNH CHÍNH 1. Họ và tên bệnh nhân ( in hoa ):................................................................................................... 2. Ngày, tháng, năm, sinh:.................................................................................Dân tộc:................ 3. Nghề nghiệp:............................................................................................................................... 4. Địa chỉ thường trú:...................................................................................................................... 5. Họ và tên chồng:......................................................................................................................... 6. Nghề nghiệp chồng:......................................................................................Tuổi:..................... 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:................................................................................................................ III. BỆNH SỬ: ( ngày đầu của kỳ kinh cuối, diễn biến quá trình mang thai, số lần chích ngừa uốn ván, tình trạng (sinh hiệu, cơn go, tim thai, độ xóa mở cổ tử cung, độ lọt, tình trạng ối,…) và xử trí ban đầu lúc nhập viện): .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. Trường CĐYT Lâm Đồng trang 1 / 8 Bệnh án sản khoa.doc .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. IV. TIỀN SỬ 1. Bản thân: 1.1. Sản khoa:  Lấy chồng năm:.......................................PARA: ...............................  Những tai biến của lần sinh trước:............................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 1.2 Phụ khoa:  Tiền sử viêm bộ phận sinh dục:................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. ..............................................................................................................................................................  Đã điều trị mấy lần:...................................................................................................................  Tiền sử bị bệnh u nang buồng trứng, u xơ cổ tử cung: .............................................................................................................................................................. .............................................................................................................................................................. ..............................................................................................................................................................  Sử dụng biện pháp KHHGĐ:..................................................................................................... 1.3 Các bệnh khác ( ảnh hưởng đến cuộc sanh lần này ):  Bệnh tim mạch, huyết áp, gan, thận, nội tiết:............................................................................. .............................................................................................................................................................. .............................................................................................................................................................. ..............................................................................................................................................................  Mổ vùng bụng dưới, khung chậu:..............................................................................................  Bệnh sốt rét, thương hàn:........................................................................................................... 2. Gia đình: ( chồng )  Bệnh lây qua đường tình dục:.................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................  Bệnh truyền nhiễm:................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................ Trường CĐYT Lâm Đồng trang 2 / 8 Bệnh án sản khoa.doc V. KHÁM BỆNH ……...giờ.…...phút – ngày….....tháng….....năm….… A. KHÁM MẸ 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: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.4. Thận – Tiết niệu – Sinh dục: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.5. Thần kinh: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2.6. Cơ quan khác: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. Trường CĐYT Lâm Đồng trang 3 / 8 Bệnh án sản khoa.doc 3. Sản – Phụ khoa: 3.1 Khám vú ( mô tả bầu vú, núm vú, khối u ở vú: vị trí, kích thước, mật độ, độ di động,… ( nếu có ) ): .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 3.2 Khám bụng ( mô tả hình thù tử cung, vết mổ bụng ( nếu có ), sờ nắn theo 4 thủ thuật Leopol ): .............................................................................................................................................................. .............................................................................................................................................................. ..............................................................................................................................................................  Chiều cao tử cung:...................................cm Vòng bụng:......................cm  Cơn go tử cung:....................................... Tim thai:...............lần / phút 3.3 Khung chậu ngoài:  Đường kính trước sau:...............................................................................................................  Hình trám Michaelis:................................................................................................................. 3.4 Âm hộ - tầng sinh môn: Dễ dãn nở rắn chắc hẹp không hẹp 3.5 Khung chậu trong:  Góc hòm vệ:..............................................................................................................................  Gai hông:...................................................................................................................................  Mõm nhô:.................................................................................................................................. 3.6 Hiện tượng:  Xóa mở cổ tử cung:...................................................................................................................  Ối: ối phồng ối dẹt ối quả lê  Ối vỡ: tự nhiên bấm ối  Nước ối: nhiều trung bình ít  Độ lọt của ngôi: cao chúc chặt lọt  Ngôi:…………………………thế……………………….kiểu thế………..…………………… 4. Trường hợp mẹ đã sanh cần khám những phần sau: 4.1 khám tổng trạng và các bộ phận ( đã nêu ở trên ) 4.2 Khám sản phụ khoa:  Khám vú: ( mô tả bầu vú, núm vú, khối u ở vú: vị trí, kích thước, mật độ, độ di động ( nếu có ), sự bài tiết sữa ) .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. ..............................................................................................................................................................  Khám bụng ( nhìn mô tả bụng, mô tả sự co hồi tử cung, mật độ tử cung, điểm đau khu trú tại bụng): .............................................................................................................................................................. Trường CĐYT Lâm Đồng trang 4 / 8 Bệnh án sản khoa.doc .............................................................................................................................................................. .............................................................................................................................................................. ..............................................................................................................................................................  Khám và mô tả sản dịch và vết may tầng sinh môn ( nếu có ) .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. B. KHÁM BÉ  Vòng đầu:…………cm Chiều dài:……….cm Cân nặng:……….kg  Khám da, niêm, bướu, thóp:................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................  Tuần hoàn:............................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................  Hô hấp:..................................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................  Phản xạ, trương lực cơ:........................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................  Rốn:..........................................................................................................................................  Tình trạng bú:..........................................................................................................................  Sự bài tiết:................................................................................................................................ VI. KẾT QUẢ CẬN LÂM SÀNG 1. Công thức máu: Kết quả 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 2. Xét nghiệm nước tiểu: ngày................................... .............................................................................................................................................................. .............................................................................................................................................................. Trường CĐYT Lâm Đồng trang 5 / 8 Bệnh án sản khoa.doc .............................................................................................................................................................. .............................................................................................................................................................. 3. Siêu âm: …………………………. ngày................................... .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 4. Cận Lâm Sàng khác:……………. ngày................................... .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. VII. CHẨN ĐOÁN – BIỆN LUẬN 1. Chẩn đoán ( số lần mang thai, tuổi thai, ngôi, thế, kiểu thế ): .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2. Chẩn đoán giai đoạn chuyển dạ .............................................................................................................................................................. .............................................................................................................................................................. 3. Chẩn đoán những bệnh đi kèm: .............................................................................................................................................................. .............................................................................................................................................................. 4. Biện luận: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. Trường CĐYT Lâm Đồng trang 6 / 8 Bệnh án sản khoa.doc .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. VIII. ĐIỀU TRỊ 1. Thuốc cần sử dụng .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2. Những việc cần theo dõi khi chuyển dạ: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 3. Hướng dẫn chế độ ăn .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 4. Vấn đề vệ sinh, vận động của thai phụ: .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 5. Chuẩn bị quần áo cho mẹ và bé: .............................................................................................................................................................. .............................................................................................................................................................. IX. TIÊN LƯỢNG .............................................................................................................................................................. X. PHÒNG BỆNH VÀ GIÁO DỤC SỨC KHỎE 1. Trong thời gian nằm tại nằm viện  Đối với khoa, phòng:................................................................................................................. ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................  Đối với cán bộ y tế:................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................  Đối với sản phụ:......................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................  Đối với thân nhân người bệnh:.................................................................................................. Trường CĐYT Lâm Đồng trang 7 / 8 Bệnh án sản khoa.doc ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ 2. Trong thời gian ra viện  Sử dụng thuốc:........................................................................................................................... ........................................................................................................................................................  Chế độ ăn, sinh hoạt:................................................................................................................. ........................................................................................................................................................ ........................................................................................................................................................  Vệ sinh hàng ngày:.................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................  Chăm sóc bé:............................................................................................................................. ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................  Biện pháp KHHGĐ:..................................................................................................................  Tái khám:...................................................................................................................................  Chương trình tiểm chủng cho bé:............................................................................................... ........................................................................................................................................................ Đà Lạt, ngày……tháng……năm…… Người làm bệnh án Họ và tên y sinh:......................................................................... Trường CĐYT Lâm Đồng trang 8 / 8 Bệnh án sản khoa.doc