Trường Đại Học Y Khoa Phạm Ngọc Thạch Họ tên SV :…………………………………..                                                          ...
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b. Tim: .....................................................................................................................
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Benh an noi khoa

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Benh an noi khoa

  1. 1. Trường Đại Học Y Khoa Phạm Ngọc Thạch Họ tên SV :………………………………….. BỆNH ÁN NỘI KHOA Tổ : ………………………….Lớp: YCT2010I. HÁNH CHÍNH:Họ tên:....................................................................Giới tính:……….Năm Sinh:…..........(Tuổi):………Nghề nghiệp:.................................................................................................................................................Địa chỉ:..........................................................................................................................................................Ngày nhập viện:……./……/………Ngày làm bệnh án: :……./……/………II. LÝ DO NHẬP VIỆN: ............................................................................................................................III. BỆNH SỬ:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................IV. TIỀN CĂN:1. Bản thân: - Bệnh lý nội khoa:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. - Bệnh lý ngoại khoa:...................................................................................................... - Bệnh lý sản khoa: ........................................................................................................ - Thói quen: ....................................................................................................................2. Gia đình: ....................................................................................................................................................V. LƯỢC QUA CÁC CƠ QUAN: ( Triệu chứng cơ năng khác trong thời gian bệnh sử diễn ra)1. Tai – Mũi – Họng: .............................................................................................................................................................................................................................................................................................................2. Hệ hô hấp: ................................................................................................................................................. 1 Trang
  2. 2. ........................................................................................................................................................................3. Hệ tim mạch: .....................................................................................................................................................................................................................................................................................................................4. Hệ tiêu hóa: .......................................................................................................................................................................................................................................................................................................................5. Hệ tiết niệu sinh dục: ........................................................................................................................................................................................................................................................................................................6. Hệ vận động: .....................................................................................................................................................................................................................................................................................................................7. Hệ thần kinh:......................................................................................................................................................................................................................................................................................................................8. Khác: .........................................................................................................................................................VI. KHÁMTình trạng lúc nhập viện: ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Thăm khám hiện tại:1. Tổng quát:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Đầu mặt cổ a. Mắt: .............................................................................................................................................................................................................................................................................................................................. b. Tai: ............................................................................................................................................................................................................................................................................................................................... c. Mũi: .............................................................................................................................................................................................................................................................................................................................. d. Miệng và họng: .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... e. Cổ: ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Ngực: a. Lồng ngực – Phổi : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 2 Trang
  3. 3. b. Tim: ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ c. Vú: .................................................................................................................................................................................................................................................................................................................................4. Bụng :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................5. Tứ chi cột sống: a. Da – Lông – Móng : ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................... b. Mạch máu: .................................................................................................................................................................................................................................................................................................................... c. Cơ: ................................................................................................................................................................................................................................................................................................................................. d. Khớp: ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... e. Cột sống: ..............................................................................................................................................6. Thần kinh: .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................VII. TÓM TẮT BỆNH ÁN:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................VIII. ĐẶT VẤN ĐỀ:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 3 Trang
  4. 4. ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................IX. CHẨN ĐOÁN SƠ BỘ : ................................................................................................................................................................................................................................................................................................* Chẩn đoán phân biệt: ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................X. CẬN LÂM SÀNG ĐỀ NGHỊ:1. Thường quy: ......................................................................................................................................................................................................................................................................................................................2. Theo vấn đề: .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 4 Trang

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