1. Life characteristics
Body temperature (T)(C), pulse rate (p) (beats/min), respiratory frequency (r) (beats/min), blood pressure (BP)(kPa).
2. General situation
Development (normal and abnormal), nutrition (good, medium, poor), posture (autonomous, passive, forced or uneasy), gait, face and expression (acute and chronic diseases, painful expressions, anxiety, fear, quietness), consciousness (clear, vague, sleepy, coma), and cooperation with doctors.
3. Skin and mucous membrane
Color (flushing, cyanosis, pallor, yellow staining, pigmentation), temperature, humidity, elasticity, edema, rash, petechiae, subcutaneous nodules or lumps, spider nevus, ulcers and scars, hair distribution, etc. ; If yes, the location, scope (size) and shape should be described.
4. Lymph nodes
Whether there is swelling (location, size, number, tenderness, hardness, mobility, fistula, scar, etc.). ) in systemic or local superficial lymph nodes.
5. Head and its organs
(1) Skull: size, shape, tenderness, lump, hair (number, color, distribution, baldness, alopecia areata). The baby should record the size, fullness or depression of the anterior fontanel.
(2) Eyes: vision (check if necessary), eyebrows (shed and thinned), eyelashes (trichiasis), eyelids (edema, movement and drooping), eyeballs (protrusion, depression, movement, strabismus and tremor), conjunctiva (congestion, bleeding, pallor and edema), sclera (yellow staining) and cornea.
(3) Ear: hearing, presence of deformity, secretion and tenderness of mastoid process.
(4) Nose: whether there is deformity, alar flap, secretion, bleeding, obstruction and tenderness in the paranasal sinus area.
(5) Oral cavity: bad breath, saliva secretion, lips (deformity, discoloration, herpes, chapped mouth, ulcer, crooked mouth), teeth (dental caries, missing teeth, dentures, residual roots, such as: dental caries 3+4), gums (discoloration, swelling, pus overflow, bleeding, lead thread.
6. Neck
Symmetry, rigidity, jugular vein dilatation, hepatojugular vein reflux sign, abnormal pulsation of carotid artery, lump, tracheal position, thyroid gland (size, hardness, tenderness, nodule, tremor, murmur, up-and-down mobility during swallowing).
7. Chest
(1) Thoracic (symmetry, deformity, local uplift or collapse, tenderness), respiration (frequency, rhythm, depth), abnormal pulse, varicose veins. * Describe the disease according to the inspection requirements.
(2) Lung:
Visual diagnosis: respiratory movement (bilateral comparison), respiratory type, whether the intercostal space is widened or narrowed.
Palpation: Trembling speech, feeling of pleural friction and subcutaneous torsion.
Percussion sound: Percussion sound (unvoiced sound, voiced sound, solid sound, unvoiced sound or drum sound), lower lung boundary and lower lung boundary activity.
Auscultation: Breathing sounds (nature, strength, abnormal breathing sounds), dry and wet rales and pleural friction sounds, voice conduction (pay attention to symmetrical parts), etc.
(3) the heart:
Visual diagnosis: apical pulsation (position, range, intensity), accompanied by unintentional anterior uplift.
Palpation: apical pulsation (nature, location, range and intensity), tremor (location and duration) and pericardial fricative sound.
Percussion: The left and right voiced boundary (relative voiced boundary) of the heart is represented by the distance from the rib to the midline, and the distance from the midline of the clavicle to the anterior midline is represented by a table (Table 1).
Auscultation: heart rate, heart rhythm, heart sounds (intensity, division, comparison between P2 and A2, extra heart sounds, galloping rhythm) and whether there are murmurs (position, nature, period, intensity, conduction direction) and pericardial fricative sounds.
Right side (cm) left side of intercostal space (cm)
Ⅱ
Ⅲ
Ⅳ
Ⅴ
The clavicle midline is cm away from the anterior midline.
8. Vascular examination
(1) radial artery: pulse rate, rhythm (regular or irregular, short pulse), odd pulse and cross pulse, pulse comparison between left and right radial arteries, and the nature and tension of arterial wall.
(2) Signs of peripheral blood vessels: whether there is capillary pulsation, sound shooting and water pulse.
9. abdomen
(1) Optic rash: appearance (symmetry, flattening, swelling and depression), respiratory movement, umbilical cord, presence or absence of rash, stripes, scars, lumps, varicose veins (if any, record the blood flow direction), gastrointestinal peristalsis waves, and upper abdominal pulsation.
(2) palpation:
Abdominal wall: abdominal wall tension, tenderness, rebound pain, fluid tremor and mass (position, size, shape, hardness, tenderness, pulsation and mobility). Abdominal circumference should be measured when there is ascites or abdominal mass.
Liver: size (the right lobe is indicated by the number of centimeters from the midline of the right clavicle to the lower edge of the liver, and the left lobe is indicated by the number of centimeters from the xiphoid process to the lower edge of the left lobe of the liver), texture, surface, edge, tenderness and pulsation.
Gallbladder: size, shape, tenderness or not
Spleen: size, hardness, surface, marginal state, tenderness or not. Giant spleen is represented by three lines (figure 1).
Kidney: size, shape, hardness, mobility, tenderness of renal area and ureter tenderness point, bladder swelling.
(3) Percussion: liver dullness, whether there is percussion pain in the liver area, moving dullness, high drum sound, and percussion pain in the kidney area.
(4) Auscultation: bowel sounds (normal, enhanced, weakened or disappeared), whether there is water vibration sound or vascular murmur.
10. anus and rectum
Whether there are hemorrhoids, anal fissure, rectocele and anal fistula. Attention should be paid to anal sphincter tension, stenosis, internal hemorrhoids, tenderness, prostate size and hardness during anal digital examination; Pay special attention to whether there are palpable masses (size, location, hardness, activity, etc.). ). Pay attention to the color of the finger cover when checking the ring.
1 1. qianyin
Do the corresponding examination according to the condition.
(1) Male: distribution of pubic hair, whether there are abnormal development, scar of dry shade, urethral secretion, foreskin, testis, epididymis, spermatic cord, varicocele and hydrocele.
(2) Female: Please have a gynecological examination if necessary. Male doctors must be accompanied by female medical staff.
12. Spine and limbs
(1) Spine: presence of deformity, tenderness, percussion pain and mobility.
(2) Limbs: presence of deformity, clubbed fingers (toes), varicose veins, fractures, edema, muscular atrophy, limb paralysis or increased muscle tension, and joints (redness, swelling, pain, tenderness, effusion, dislocation, limited movement and rigidity).
65438+
(1) Physiological reflex: corneal reflex, abdominal wall reflex, testicular lifting reflex, biceps brachii reflex, triceps brachii reflex, knee tendon reflex and achilles tendon reflex.
(2) Pathological reflex: babinski's sign, etc.
(3) Meningeal irritation signs: neck rigidity, Brudzinski sign and Keniger sign.
(4) Exercise, sensory and other nervous system examination when necessary.
14. Professional information
Record the special situation of special diseases, such as surgery, ophthalmology, gynecology, etc. (See the main points of medical record writing in each major).
(3) Laboratory and instrument inspection
Record the laboratory and instrument inspection results related to diagnosis. If the examination is conducted before admission, the place and date of the examination should be indicated.
(4) Abstract
Summarize the comprehensive medical history, physical examination, laboratory examination and instrument examination, and highlight the positive findings to prompt the diagnosis basis.
(5) Preliminary diagnosis
Write it on the last right of the medical record. According to primary diseases and secondary diseases, diseases related to the chief complaint or life-threatening diseases rank first. In addition to the full name of the disease, the diagnosis should also include the diagnosis of the etiology, anatomical location and function of the disease as far as possible.