revision-內科胃腸科.doc - .Acute cholecystitis Chief...

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胃腸科標準病歷範本 . Acute cholecystitis Chief complaint : RUQ abdominal pain since ?(date) Present illness: This XX–year-old woman/man complained of abdominal pain for XX days. She/he had a similar experience of acute cholecystitis years ago. Her/his abdominal pain was located in the epigastrium/RUQ, dull and constant in nature, radiating to her back, and worsened after eating greasy foods. The pain was associated with vomiting.and mild fever. There was/wasn’t jaundice. She/he denied change in stool habit, chronic diarrhea and constipation. Besides, she/he denied chills, poor oral intake and recent weight loss. Under the impression of acute cholecystitis, she/he was admitted to GI ward for further evaluation and treatment. Past history : 1.Past medical history: # Cardiovascular disease - CAD, hyperlipidemia, hypertension, DM, stroke # Hepatitis B or C carrier - # Current medications – NSAIDs, aspirin, steroids 2.Past surgical history: # no gastrectomy/colectomy/splenectomy Personal history # Smoking: ? PPD for years # Alcohol: type, amount, duration # Herbs used: denied # Occupation: ? # Travel history: denied # Animal exposure history: denied Family history : # No family history of hepatitis, diabetes mellitus, hypertension or malignancy Review of system: Constitutional: weakness(-), fatigue(-), fever(-), chills (-), cold sweating (-) body weight loss (-) Skin: pigmentation(-), jaundice(-), cyanosis(-), rashes(-), bruises(-), bulla (-)
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HEENT: a. Head--headache(-), dizziness(-), vertigo(-), syncope(-) b. Eyes--red eye(-), loss of vision(-), photophobia(-), pain(-) c. Nose--rhinorrhea(-), nasal congestion(-), postnasal drip(-) d. Ears--pain(-), discharge(-), hearing impairment(-), tinnitus(-) e. Mouth and throat--sore throat(-), hoarseness(-), oral ulcer(-) dysphagia(-), odynophagia(-) Respiratory system: cough(-), wheezing(-), dyspnea(-), chest tightness(-), hemoptysis(-), sputum (-) Cardiovascular system: dyspnea on exertion(-), paroxysmal nocturnal dyspnea(-),orthopnea (-), chest discomfort(-), palpitation(-) Gastrointestinal system: nausea(-), vomiting(-), heartburn(-), constipation(-), change of stool caliber(-), diarrhea(-) hematemesis(-), tarry stool/melena(-), bloody stool(-) abdominal pain(-), abdominal distension(-) Genitourinary system: dysuria(-), frequency(-), hematuria(-), nocturia(-), Foley catheter indwelling(-) Metabolic and endocrine system: moon face(-), central obesity(-), lower legs edema(-), heat/cold intolerance(-), polydipsia(-), polyuria(-), polyphagia(-) Neurological system: syncope(-), seizure(-), speech disturbance(-) numbness(-), weakness(-), ataxia(-), incontinence(-) Musculoskeletal system: low back pain(-), cramping(-), muscle atrophy(-), pain(-), swelling(-), intermittent claudication(-) Psychiatric: hallucination(-), delusions(-), anxiety (-), depression(-), agitation(-), suicide intention(-) Physical examination : Body weight: kg Body height: cm BMI: kg/m 2 General appearance: well/fair/acute/chronic ill-looking Catherization: s/p endotracheal tube intubation/CVP insertion/
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NG insertion, Foley catheterization Conscious level: alert, arousable, drowsy, coma GCS: EVM Skin: no icterus, no bruises/petechiae/ecchymosis, no spider angioma HEENT: pale/pink conjunctiva, no icteric sclera, pupil sizes(3.0mm, 3.0mm), light reflex(+/-, +/-) no injected throat, no oral ulcer Neck: supple, no enlarged thyroid gland, no jugular vein engorgement
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