病史采集万能公式 病例分析指导模板.docx

1、病史采集万能公式 病例分析指导模板病史采集万能公式 病例分析指导模板病史采集万能公式 一、现病史 1.根据主诉及相关鉴别询问: (1)病因和诱因 有无受凉、饮食不洁、服用药物、外伤、受刺激、劳累等。 (2)主症的特点 程度、性状、次数、颜色、缓急、量、性质、部位、时间等。 若有附症，亦应加以特点描述。 (3)伴随症状 (4)全身症状 病后的一般状态，即饮食、睡眠、二便、体重、精神状态。 2.诊疗经过: (1)是否到医院就诊,做过何种检查, (2)是否做过治疗,服用何种药物,疗效如何, 二、既往史 1、药物过敏史、手术史、传染病接触史。 2、相关病史 本系统相关疾病和并发症 (说明:黑体部分是直

2、接摘录部分，适当增减。蓝体部分为发挥部分，病史采集的主体部分。) 病例分析指导模板: 本例初步诊断:(要写全) 1. xxx 2. xxx 诊断依据: 1、 病史 2、 体检 3、 辅助检查 鉴别诊断 1、 xxx 2、 xxx 3、 xxx 进一步检查 1、 进一步确诊该病所应完善的检查 2、 排除该病所做的检查 3、 该病病情发展变化所做检查(实在不会就写血常规、肝肾功等) 治疗原则 1、 一般治疗 2、 病因治疗 3、 对症治疗 4、 外科治疗或放化疗、中医中药治疗、免疫治疗。 附: 呼吸系统诊断公式: 1、 急性上呼吸道感染=咽痛+咳嗽+发热 2、 肺炎 (1) 大叶性肺炎=成人+受凉

3、+高热+铁锈色痰 (2) 克雷伯杆菌肺炎=砖红色痰+x线空洞 (3) 支原体肺炎=儿童+刺激性干咳+关节疼+抗生素无效 (4) 支气管肺炎=婴幼儿+发热+呼吸困难(鼻翼扇动、三凹症) (5) 金黄色葡萄球菌=高热+胸痛+脓血痰+x线片状影 3、 结核病 spacing of 100mm. C, line line line nearby. D, spare wire unified terminal strip Terminal (terminal strip at the top of the vertical, horizontal terminal strip from the harn

4、ess to Terminal Pai end at the beginning), length to ensure as far as Terminal and set aside. After e, form a wire harness, cable, line. When the line should be in the core wire for better identification and marking on the cards will be prepared in advance, alternate core core content for the cable

5、numbering. F, finish line, according to the corresponding terminal locations, wire one by one from the bunch out, pulling line, should be kept parallel to each other and more. Core dark as possible, determined in accordance with specific conditions, it is required that: neat, beautiful, shapely, ple

6、asing to the eye. 7.6.2 wiring technology, out of the core wire according to Terminal position, cut off the excess, with wire stripping pliers or electrician knife stripped of insulation, so that connection. Stripping should not damage the copper core. B, core wire on the oxide and chip-insulated el

7、ectricians knife scrape. C, core processing has been completed, thread round long nose pliers in a clockwise direction. Circle with the screw in the direction of spin in the same direction, circle should be appropriate, it is best to slightly larger than the screws, bent round the circle and the len

8、gth of root and appropriate so set screw is screwed on tight. D, when on the crimp-type terminals when wiring, threads do not have to bend. Insulating part should be careful not to press it into a Terminal, and make the loop doesnt make sense and to prevent bad head crimping, fell down, causing an o

9、pen circuit. After wiring, may be tried. E, crimping Terminal crimping, wire and Terminal contact is good, solid, not subject to mechanical strain, and ensure the insulation level. F, cables, such as when there is a bare copper ground wire, bare copper wire with a plastic pipe should be set. G, when

10、 wiring wiring must be in radians. H, terminal screws (1) 肺结核=青壮年+咳血+午后低热+夜间盗汗+抗生素治疗无明显疗效 (2) 结合性胸膜炎=结核+胸膜积液体征(胸语颤消失+叩诊实音) (3) 结合性心包炎=结核+心包积液体征(心前区痛+呼吸困难+上腹部闷胀+下肢浮肿) (4) 肠结核=结核+腹部症状(腹痛、腹泻、右下腹部肿块) (5) 结合性腹膜炎=结核+腹部炎症(腹痛、腹泻、腹部柔韧感) (6) 肾结石=结核+膀胱刺激症+肾实质变薄并有破坏(严重的膀胱刺激症应想到结核病变) 4、 支气管扩张=童年有麻疹百日咳后支气管肺炎迁延不愈病

11、史+咳嗽+脓痰+咯血 5、 COPD=老年人(吸烟史)+咳、痰、喘+桶装胸+肺功能检查一秒率FEV1/FVC%70% 6、 肺脓肿=脓臭痰+高热+x线/CT示液平面 7、 肺癌=中老年+痰中带血+刺激性咳嗽+消瘦+X线毛刺 8、 肺心病=慢性肺部疾病病史+心脏扩大 演变顺序:慢支-肺气肿-肺心病 9、 支气管哮喘=阵发性或周期性喘息+听诊哮鸣音+过敏史 10、 呼吸衰竭=慢性肺部疾病病史+发绀+血气分析指标 I型:PaO260mgHg PaCO2正常-重症肺炎诱发 II型:PaO250mgHg-慢阻肺诱发 11、 胸部闭合性损伤 (1) 张力性气胸=胸外史+广泛皮下气肿+气管偏移+叩诊鼓音+呼

12、吸音消失 (2) 血胸=胸外伤史+气管偏移+叩诊浊音+呼吸音减弱+X线肋膈角消失，弧形高密度影 (3) 肋骨骨折=胸外伤史+骨擦音 呼吸系统检查项目: 1、 胸片、胸部CT 2、 PPD、血沉 3、 痰培养+药敏试验、痰找结核杆菌 4、 肺功能 5、 肝肾功能 6、 血气分析 7、 纤维支气管镜 8、 痰液脱落细胞检测 9、 淋巴结活检 10、 血常规、电解质 呼吸系统疾病治疗原则: 1、 一般治疗:休息、加强营养、预防感染/吸氧 2、 对症治疗/药物治疗 (1) 看感染治疗:广谱抗生素或联合用药 (2) 抗结核治疗:早恋适当规劝(早期、适量、联合、规律、全程) (3) 抗休克:扩容 (4)

13、控制咯血:垂体后叶素 (5) 解热、止咳、平喘、祛痰 (6) 纠正酸碱平衡失调 3、 肿瘤 (1) 手术治疗 (2) 放疗+化疗+免疫治疗+中医中药治疗 心血管系统诊断公式: 1、 冠心病=胸骨后压窄性疼痛 (1) 心绞痛=胸骨后压窄性疼痛30分钟，舌下含服硝酸甘油或休息后不能缓解+大汗淋漓+濒死感+ECG:ST段弓背向上抬高 spacing of 100mm. C, line line line nearby. D, spare wire unified terminal strip Terminal (terminal strip at the top of the vertical, h

14、orizontal terminal strip from the harness to Terminal Pai end at the beginning), length to ensure as far as Terminal and set aside. After e, form a wire harness, cable, line. When the line should be in the core wire for better identification and marking on the cards will be prepared in advance, alte

15、rnate core core content for the cable numbering. F, finish line, according to the corresponding terminal locations, wire one by one from the bunch out, pulling line, should be kept parallel to each other and more. Core dark as possible, determined in accordance with specific conditions, it is requir

16、ed that: neat, beautiful, shapely, pleasing to the eye. 7.6.2 wiring technology, out of the core wire according to Terminal position, cut off the excess, with wire stripping pliers or electrician knife stripped of insulation, so that connection. Stripping should not damage the copper core. B, core w

17、ire on the oxide and chip-insulated electricians knife scrape. C, core processing has been completed, thread round long nose pliers in a clockwise direction. Circle with the screw in the direction of spin in the same direction, circle should be appropriate, it is best to slightly larger than the scr

18、ews, bent round the circle and the length of root and appropriate so set screw is screwed on tight. D, when on the crimp-type terminals when wiring, threads do not have to bend. Insulating part should be careful not to press it into a Terminal, and make the loop doesnt make sense and to prevent bad

19、head crimping, fell down, causing an open circuit. After wiring, may be tried. E, crimping Terminal crimping, wire and Terminal contact is good, solid, not subject to mechanical strain, and ensure the insulation level. F, cables, such as when there is a bare copper ground wire, bare copper wire with

20、 a plastic pipe should be set. G, when wiring wiring must be in radians. H, terminal screws V1-V6广泛前壁性 V1-V3前间壁 V3-V5局限前壁 V5-V6前侧壁 II、III、aVF、下壁 I、aVL高侧壁 心功能Killip分级:评估急性心肌梗死患者心功能 I级:无明显心衰，无肺部罗音 II级:左心衰，肺部罗音小于50%肺野 III级:急性肺水肿，肺部罗音大于50%肺野 IV级:心源性休克 、 高血压=不同日三次以上测血压140/90 2分级: 1级 140-159/90-99 2级 160-

21、179/100-109 3级 180/110以上 单纯收缩期高血压140 90 3、 左心衰=粉红色泡沫痰+呼吸困难(夜不能平卧、端坐呼吸、活动后) 右心衰=颈静脉怒张+双下肢水肿+肝大 心功能分级:I级 日常活动不受限 II级 活动后轻度受限 III级 活动后明显受限 IV级 休息时出现症状 4、 心律失常 (1) 房心律绝对不等+脉短绌+心电图f波+第一心音强弱不等 (2) 阵发性室上性心动过速=阵发性心慌+突发停止+ECG示无P波、心率160-250次/分 (3) 阵发性室性心动过速=突发性心慌+既往发作史+ECG示3次以上快的宽大畸形QRS波群+心室夺获/室性融合波 (4) 其他。 5

22、、 心瓣膜病 (1) 二尖瓣狭窄=呼吸困难(劳力性、阵发性、夜间、端坐呼吸、急性肺水肿)+急性大量咯血、粉红色泡沫痰+梨状心+舒张期隆隆样杂音 (2) 二尖瓣关闭不全=急性左心衰/慢性晚期出现左心衰或全心衰+心尖部粗糙的全收缩吹风样杂音，向腋下或左肩胛下传导 (3) 主动脉瓣狭窄=呼吸困难+心绞痛+晕厥+喷射性杂音并向颈部传导 (4) 主动脉瓣关闭不全=心悸+心绞痛+夜间阵发性呼吸困难+AustinFliht杂音+周围血管征(水冲脉、Musset征、颈动脉搏动明显、毛细血管搏动征、动脉枪击音及Duroziez征) 6、 休克 体征=脉率增快+血压下降+脉搏细速+四肢发冷 (1) 失血性休克=休

23、克体征+出血 (2) 心源性休克=休克体征+左心衰 心血管系统检查: 1、 心电图、动态心电图 2、 超生心动图 3、 胸部X线 4、 眼底检查(高血压)、放射性核素 5、 心肌酶谱 6、 血气分析 7、 血常规、血脂、血糖、血钾、肝肾功 8、 心导管 9、 冠脉造影 10、 心肌坏死标记物(肌红蛋白、肌钙蛋白、肌酸激酶同工酶CK-MB) 心血管系统治疗 1、 一般治疗:注意休息、改变生活方式(戒烟、低脂低纳饮食、适度运动)监测、护理 spacing of 100mm. C, line line line nearby. D, spare wire unified terminal strip

24、 Terminal (terminal strip at the top of the vertical, horizontal terminal strip from the harness to Terminal Pai end at the beginning), length to ensure as far as Terminal and set aside. After e, form a wire harness, cable, line. When the line should be in the core wire for better identification and

25、 marking on the cards will be prepared in advance, alternate core core content for the cable numbering. F, finish line, according to the corresponding terminal locations, wire one by one from the bunch out, pulling line, should be kept parallel to each other and more. Core dark as possible, determin

26、ed in accordance with specific conditions, it is required that: neat, beautiful, shapely, pleasing to the eye. 7.6.2 wiring technology, out of the core wire according to Terminal position, cut off the excess, with wire stripping pliers or electrician knife stripped of insulation, so that connection.

27、 Stripping should not damage the copper core. B, core wire on the oxide and chip-insulated electricians knife scrape. C, core processing has been completed, thread round long nose pliers in a clockwise direction. Circle with the screw in the direction of spin in the same direction, circle should be

28、appropriate, it is best to slightly larger than the screws, bent round the circle and the length of root and appropriate so set screw is screwed on tight. D, when on the crimp-type terminals when wiring, threads do not have to bend. Insulating part should be careful not to press it into a Terminal,

29、and make the loop doesnt make sense and to prevent bad head crimping, fell down, causing an open circuit. After wiring, may be tried. E, crimping Terminal crimping, wire and Terminal contact is good, solid, not subject to mechanical strain, and ensure the insulation level. F, cables, such as when th

30、ere is a bare copper ground wire, bare copper wire with a plastic pipe should be set. G, when wiring wiring must be in radians. H, terminal screws 2、 高血压: (1) 药物治疗:利尿剂、受体阻止剂、钙通道阻滞剂、血管紧张素转换酶抑制剂、血管紧张素II受体阻滞剂 (2) 控制合并症。 3、 冠心病:控制心律失常、改善心功能、溶栓或介入治理、控制休克、纠正心衰、抗凝及抗血小板药物治理 4、 房颤:药物复律，选胺碘酮。减慢心室率，选用西地兰。 5、 心

31、衰:利尿、ACEI、受体阻止剂、正性肌力药(地高辛、多巴胺)、心脏起搏器 6、 瓣膜病:病因治疗、瓣膜置换等。 泌尿系统疾病诊断公式: 1、 肾小球肾炎=眼睑或颜面部水肿+青少年+链球菌感染史+C3下降+血尿、蛋白尿、高血压 2、 尿路感染 (1) 肾盂肾炎=女性+腰痛+发热+脓尿、白细胞管型 (2) 慢性肾盂肾炎急性发作=尿路损伤史+膀胱刺激症反复发作+腰痛+发热+肾区扣痛+血白细胞? (3) 下尿路感染=已婚女性+发热+膀胱刺激症 3、 结石 (1) 上尿路结石=活动后出现血尿+腰部绞痛+B超强回声伴声影或X线片 (2) 膀胱结石=男性+排尿突然中断、疼痛放射至阴茎头部、排尿困难、膀胱刺激征+体位改变疼痛缓解+B超/X线 4、 肾癌=老年人+无痛性肉眼血尿 5、 肾衰=多年肾炎病史+血尿蛋白尿高血压+血肌酐?(待长期133、失代偿442、衰竭期707、尿毒症期) 6、 前列腺增生=老年人+尿频+进行性排尿困难 泌尿系统疾病检查 、 腹部B超、X线 12、 血尿常规、血沉、肾功、血气 3、 肾盂造影 4、 穿刺活检 5、 妇科检查 6、 血肌酐、肾小球滤过率 7、 放射性核素肾图 8、 膀胱镜 泌尿系统治疗: 1、 一般治疗:注意休息，低纳低蛋白饮食 2、 对症治疗:抗感染、利尿降压、透析、纠正水电解质酸碱失调 3、 外科治疗 4、 肿瘤治疗 5、 血液透