Main complaint:...
1. Vital signs
Body temperature (T) (C), pulse rate (P) (times/min), respiratory rate (R) (times/min), blood pressure (BP) (kPa).
2. General conditions
Development (normal or abnormal), nutrition (good, moderate, poor), body position (autonomous, passive, forced or restless), gait, face Expression (acute or chronic illness, expression of pain, worry, fear, quiet), consciousness (clear, blurred, drowsy, coma), whether you can cooperate with the doctor.
3. Skin and mucous membranes
Color (flushing, cyanosis, paleness, jaundice, pigmentation), temperature, humidity, elasticity, presence of edema, rash, petechiae and petechiae , subcutaneous nodules or masses, spider nevi, ulcers and scars, hair distribution, etc.; if any, the location, range (size) and shape, etc. should be described.
4. Lymph nodes
Whether systemic or local superficial lymph nodes are swollen (location, size, number, tenderness, hardness, mobility, fistulas, scars, etc.).
5. Head and its organs
(1) Skull: size, shape, presence or absence of tenderness, masses, hair (amount, color, distribution, baldness and alopecia areata) . Infants need to record the size of the anterior fontanel, whether it is full or sunken.
(2) Eyes: vision (check if necessary), eyebrows (falling off, sparse), eyelashes (trichiasis), eyelids (edema, movement, drooping), eyeballs (bulging, sunken, movement, etc.) Strabismus, tremor), conjunctiva (hyperemia, hemorrhage, paleness, edema), sclera (yellowing), cornea (transparency, turbidity, reflection), pupil (size, shape, symmetry, response to light and accommodation).
(3) Ears: hearing, whether there are deformities, secretions, and mastoid tenderness.
(4) Nose: Whether there is deformity, nasal flaring, secretions, bleeding, obstruction, and tenderness in the paranasal sinus area.
(5) Mouth: oral odor, saliva secretion, lips (deformity, color, herpes, cracks, ulcers, deviation of the corners of the mouth), teeth (caries, missing teeth, dentures, residual roots, in the following form Mark the location, such as: caries 3+4), gums (color, swelling, pus, bleeding, lead lines), mucosa (rash, ulcers, bleeding), tongue (shape, tongue texture, tongue coating, ulcers, movement, tremor) , deviation), tonsils (size, congestion, secretions, pseudomembranes), pharynx (color, secretions, reflexes), larynx (clear pronunciation or hoarseness, stridor, aphonia).
6. Neck
Whether it is symmetrical, whether there is ankylosis, jugular venous distention, hepatojugular reflux sign, abnormal carotid artery pulsation, masses, tracheal position, thyroid (size, Hardness, tenderness, nodules, tremor, murmur, up and down movement with swallowing).
7. Chest
(1) Thoracic cage (symmetry, deformity, local bulge or collapse, tenderness), breathing (frequency, rhythm, depth), whether there are abnormal pulses and varicose veins . *Diseases are described according to *examination requirements.
(2) Lungs:
Inspection: respiratory movement (comparison of both sides), breathing type, and whether the intercostal space is widened or narrowed.
Palpation: tremor, pleural friction and subcutaneous twisting sensation.
Percussion: Percussion sounds (voiceless, voiced, solid, supervoiceless or tympanic sounds), lower lung boundary, and mobility of the lower lung edge.
Auscultation: breath sounds (nature, intensity, abnormal breath sounds), presence or absence of dry and wet rales and pleural friction, voice conduction (pay attention to symmetrical parts), etc.
(3) Heart:
Inspection: apical pulse (location, range, intensity), whether there is precordial bulge.
Palpation: apical pulse (nature, location, range, intensity), presence or absence of tremor (location, duration) and pericardial friction.
Percussion: The left and right dullness boundaries of the heart (relative dullness boundaries) are expressed by the distance between the midline of each intercostal space, and the distance from the midclavicular line to the anterior midline is noted under the table (Table 1).
Auscultation: heart rate, heart rhythm, heart sounds (intensity, splitting, comparison of P2 and A2, extra heart sounds, gallop rhythm) with or without murmurs (location, nature, period, intensity, conduction direction) and pericardial friction rub .
Right side (cm) Left side of intercostal space (cm)
Ⅱ
Ⅲ
Ⅳ
Ⅴ
Midclavicular line cm from anterior midline
8. Vascular examination
(1) Radial artery: pulse rate, rhythm (regular or irregular, pulse Shortness of breath), presence or absence of paradoxical and alternating pulses, comparison of left and right radial artery pulses, and the nature and tension of the arterial wall.
(2) Peripheral vascular signs: presence or absence of capillary pulsation, shooting sound, and water pulse.
9. Abdomen
(1) Visual rash: appearance (symmetrical, flat, bulging, concave), respiratory movement, umbilicus, whether there are rashes, stripes, scars, masses, Varicose veins (if any, record the direction of blood flow), gastrointestinal peristaltic waves, and upper abdominal pulsations.
(2) Palpation:
Abdominal wall: Abdominal wall tension, whether there is tenderness, rebound tenderness, fluid wave tremor and masses (location, size, shape, hardness, tenderness, pulsation, mobility). Abdominal circumference should be measured when there is ascites or an abdominal mass.
Liver: size (the right lobe is expressed by the number of centimeters from the costal margin to the lower edge of the liver from the right midclavicular line, and the left lobe is expressed by the number of centimeters from the xiphoid process to the lower edge of the left liver lobe), texture, surface, edge, presence or absence Tenderness and throbbing.
Gallbladder: size, shape, and whether there is tenderness.
Spleen: size, hardness, surface, edge status, and whether there is tenderness. The giant spleen is represented by the three-line method (Fig. 1).
Kidney: size, shape, hardness, mobility, whether there is tenderness in the renal area and ureteral tender points, and whether there is bladder distension.
(3) Percussion: In the area of ??liver dullness, whether there is percussion pain in the liver area, moving dullness, high tympanic sound and percussion pain in the kidney area.
(4) Auscultation: Bowel sounds (normal, enhanced, weakened or disappeared), presence or absence of vibrating water sounds and vascular murmurs.
10. Anus and rectum
Whether there are hemorrhoids, anal fissures, anal prolapse, and anal fistulas. During digital anal examination, attention should be paid to anal sphincter tension, stenosis, internal hemorrhoids, tenderness, prostate size and hardness; special attention should be paid to the presence of palpable masses (size, location, hardness, mobility, etc.). When exiting the finger examination, you should pay attention to the color of the finger cot.
11. External genitalia
Conduct corresponding examinations according to the needs of the condition.
(1) Males: distribution of pubic hair, presence or absence of developmental deformities, scars of the penis, urethral secretions, foreskin, testicles, epididymis, spermatic cord, varicocele, and hydrocele.
(2) Women: Please have a gynecological examination if necessary. Male doctors must be accompanied by female medical staff during examinations.
12. Spine and limbs
(1) Spine: whether there is deformity, tenderness, percussion pain, and mobility.
(2) Limbs: Whether there are deformities, clubbing of fingers (toes), varicose veins, fractures, edema, muscle atrophy, limb paralysis or increased muscle tone, joints (redness, swelling, pain, tenderness, effusion) , dislocation, limited range of motion, ankylosis).
13. Nervous system
(1) Physiological reflexes: corneal reflex, abdominal wall reflex, cremasteric reflex, biceps reflex, triceps reflex, knee tendon reflex, Achilles tendon reflex.
(2) Pathological reflexes: Babinski’s sign, etc.
(3) Meningeal irritation signs: cervical rigidity, Brudzinski sign, Kernig sign.
(4) Carry out motor, sensory and other neurological examinations if necessary.
14. Specialty conditions
Record the special conditions of specialist diseases, such as surgical conditions, ophthalmology conditions, gynecological conditions, etc. (see the key points for writing medical records of each specialty).
(3) Laboratory and equipment inspection
Record laboratory and equipment inspection results related to diagnosis. If it is an examination done before admission, the location and date of the examination should be indicated.
(4) Abstract
Summarize the main information such as medical history, physical examination, laboratory examination and equipment examination, and highlight the positive findings to provide the basis for diagnosis.
(5) Preliminary diagnosis
Written on the last right half of the medical record. List the diseases in order of priority, with diseases related to the main complaint or life-threatening being listed first. In addition to the full name of the disease, the diagnosis should also include a diagnosis of the cause, anatomical location and function of the disease as much as possible.