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. xxx2. xxx诊断依据:1、病史2、体检3、辅助检查鉴别诊断1、 xxx2、 xxx3、 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+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 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 inthe core wire for better identification and 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, determined in accordancewith 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. 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 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, and make the loop doesn't make senseand 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 there is a barecopper ground wire, bare copper wire with a plastic pipe should be set. G, when 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:PaO2<60mgHg PaCO2正常---重症肺炎诱发II型:PaO2<60mgHgPaCO2>50mgHg---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CT2、 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) 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、3-5分钟/次+舌下含服硝酸甘油或休息后缓解+大汗淋漓+濒死感+ECG:ST段水平下移(2) 心梗=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, 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 shouldbe in the core wire for better identification and 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, determinedin 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, sothat connection. 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 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-typeterminals when wiring, threads do not have to bend. Insulating part should be careful not to press it into a Terminal, and make the loop doesn't 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 there 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 screwsV1-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 140-159/90-992级 160-179/100-1093级 180/110以上单纯收缩期高血压>140 <903、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。
