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Benh an noi khoa
- 1. Trường Đại HọcY Khoa Phạm Ngọc Thạch Họ tên SV :………………………………….. BỆNH ÁN NỘI KHOA Tổ : ………………………….Lớp: YCT2010 I. 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. ........................................................................................................................................................................ 3. Hệ timmạch: ............................................................................................................................................. ........................................................................................................................................................................ 4. Hệ tiêu hóa: ............................................................................................................................................... ........................................................................................................................................................................ 5. Hệ tiết niệu sinh dục: ................................................................................................................................ ........................................................................................................................................................................ 6. Hệ vận động: ............................................................................................................................................. ........................................................................................................................................................................ 7. Hệ thần kinh:.............................................................................................................................................. ........................................................................................................................................................................ 8. Khác: ......................................................................................................................................................... VI. KHÁM Tình 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. 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. ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ IX. CHẨN ĐOÁNSƠ BỘ : ........................................................................................................................ ........................................................................................................................................................................ * Chẩn đoán phân biệt: .............................................................................................................................. ........................................................................................................................................................................ ........................................................................................................................................................................ X. CẬN LÂM SÀNG ĐỀ NGHỊ: 1. Thường quy: .............................................................................................................................................. ........................................................................................................................................................................ 2. Theo vấn đề: .............................................................................................................................................. ........................................................................................................................................................................ ........................................................................................................................................................................ 4 Trang