胃腸科標準病歷範本
一.【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 deniedchills, 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 medicalhistory:
# 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 (-)
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/m2
General appearance: well/fair/acute/chronic ill-looking
Catherization: s/p endotracheal tube intubation/CVP insertion/
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
no lymphadenopathy
Chest and lungs:
symmetric and free expansion, no use of accessory muscles
breath sounds–no rales/stridor/rhonchi/wheezing
Heart:
Regular/irregular heart beats, no murmurs, no S3 & S4
Abdomen:
Inspection –flat/bulging/distended, no operation scar, no striae,
no scratch marks, no bruises, no engorged veins
Auscultation –normo/hypo/hyper-active bowel sounds, no bruits
Palpation –no tenderness, no peritoneal signs (diffuse tenderness,
muscle guarding, rebound pain), no Murphy’s sign, spleen: impalpable,
Percussion –liver span: ( )cm over right middle clavicular line, tympanic, no shifting dullness
Genitalia & digital rectal examination: no hemorrhoids, no palpable mass, normal anal tone,no blood stained on glove
Extremities:
warm/ cold, no pitting edema, no deformity
no flapping tremor
no loss of pulsation
Muscle power: RUE-grade ; LUE-grade
RLE-grade ; LLE-grade
Neurological:
no focal neurological deficits.
Laboratory and image data:
Impression: r/o Acute cholecystitis
Plan:
<Educational plan>
-Consult dietitian
-Educate patient about causes, complications, and management of acute cholecystitis
Diagnostic plan
- Arrange abdominal echo
- Check bilirubin and lipase level.
- Follow up WBC/DC.
Therapeutic plan>
- Hemodynamic plan: maintain adequate fluid intake intravenously.
- Infection control: start empiric antibiotics after blood cultures.
-Nutritional plan: NPO except water until symptoms improve
-Others:
- arrange ERCP or MRCP if gallstones pancreatitis strongly suspected.
- Pain control and antiemetics
- Consult general surgeons.
二.【Acute pancreatitis】
Chief complaint: Epigastric pain for ? hours/days
Present illness:
This XX–year-old woman complained of abdominal pain occurred since XXXXX. She had a similar experience of acute pancreatitis XXX years ago. She has drunk alcohol over the last few days. Her abdominal pain was located in the epigastrium, dull and constant in nature, radiating to her back, relieved by sitting forward, but worsened lying down. It was/wasn’t related to food intake. The pain was associated with vomiting. She denied change in stool habit, chronic diarrhea and constipation. She also denied fever/chills, poor oral intake and recent weight loss.
Under the impression of epigastric pain r/o acute pancreatitis, she was admitted to GI ward for further evaluation and treatment.
Past history:
1.Past medicalhistory:
# 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 (-)
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/m2
General appearance: well/fair/acute/chronic ill-looking
Catherization: s/p endotracheal tube intubation/CVP insertion/
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
no lymphadenopathy
Chest and lungs:
symmetric and free expansion, no use of accessory muscles
breath sounds–no rales/stridor/rhonchi/wheezing
Heart:
Regular/irregular heart beats, no murmurs, no S3 & S4
Abdomen:
Inspection –flat/bulging/distended, no operation scar, no striae,
no scratch marks, no bruises, no engorged veins
Auscultation –normo/hypo/hyper-active bowel sounds, no bruits
Palpation –no tenderness, no peritoneal signs (diffuse tenderness,
muscle guarding, rebound pain), no Murphy’s sign, spleen: impalpable,
Percussion –liver span: ( )cm over right middle clavicular line, tympanic, no shifting dullness
Genitalia & digital rectal examination: no hemorrhoids, no palpable mass, normal anal tone,no blood stained on glove
Extremities:
warm/ cold, no pitting edema, no deformity
no flapping tremor
no loss of pulsation
Muscle power: RUE-grade ; LUE-grade
RLE-grade ; LLE-grade
Neurological:
no focal neurological deficits.
Laboratory and image data:
Impression: r/o Acute pancreatitis
Plan:
<Educational plan>
-Consult dietitian.
-Educate patient about causes, complications, and management of acute pancreatitis.
Diagnostic plan
- If symptoms worsened, or fever develops, need to arrange abdominal CT with contrast.
-Follow ABGs if patient became dyspnea.
-Check Triglycerides level.
-Check Ranson’s score.
Therapeutic plan>
- Hemodynamic plan: maintain adequate fluid intake intravenously and measure body weight.
- Infection control: if fever occurred and abdominal pain worsened, start empiric antibiotics after blood cultures.
-Nutritional plan: NPO except water and water only.
-Others:
- arrange ERCP(or MRCP) if gallstones pancreatitis strongly suspected.
- Pain control.
三.【Cirrhosis】
Chief complaint: abdominal fullness for ( ) days
Present illness:
This XXX years old man has the history of 1.______; 2.______; and 3.______. He complained of abdominal fullness for XXX days/months/years with [associated symptoms: fever/chills/ anemia/ jaundice/ conscious status/ nutrient status/ urine output/ stool pattern/ skin lesions/ bleeding tendency/ dizziness/ SOB/ abdominal pain/ appetite/ bowel habit change]. His abdominal examination showed shifting dullness. Under the impression of cirrhosis with (complications), he was admitted for further evaluation and treatment.
Past history:
1.Past medicalhistory:
# 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
# Herbal medication 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 (-)
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/m2
General appearance: well/fair/acute/chronic ill-looking
Catherization: s/p endotracheal tube intubation/CVP insertion/
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
no lymphadenopathy
Chest and lungs:
symmetric and free expansion, no use of accessory muscles
breath sounds–no rales/stridor/rhonchi/wheezing
Heart:
Regular/irregular heart beats, no murmurs, no S3 & S4
Abdomen:
Inspection –flat/bulging/distended, no operation scar, no striae,
no scratch marks, no bruises, no engorged veins
Auscultation –normo/hypo/hyper-active bowel sounds, no bruits
Palpation –no tenderness, no peritoneal signs (diffuse tenderness,
muscle guarding, rebound pain), no Murphy’s sign, spleen: impalpable,
Percussion –liver span: ( ) cm over right middle clavicle line, tympanic, no shifting dullness
Genitalia & digital rectal examination: no hemorrhoids, no palpable mass, normal anal tone,no blood stained on glove
Extremities:
warm/ cold, no pitting edema, no deformity
no flapping tremor
no loss of pulsation
Muscle power: RUE-grade ; LUE-grade
RLE-grade ; LLE-grade
Neurological:
no focal neurological deficits.
Laboratory and image data:
Impression: Cirrhosis Child-Pugh ( A B C ) score ( ) with ( complications)
Plan:
Diagnostic plan
-Check Child Pugh score
-Abdominal sonography for r/o hepatoma, portal hypertension or ascites.
-Follow PES for varices and UGI bleeding.
-If ascites present, do cultures and analysis.
Therapeutic plan>
-Inderal for portal hypertension control
- If fever is suspected, do blood and ascites cultures, consult infection doctor and empiric antibiotics use
-EVL prevent further UGI bleeding
-Duphalac prevent hepatic encephalopathy
-Consider liver transplantation.
<Educational plan>
-Consult dietitian., low protein diet or low salt diet
-Educate patient about causes, complications, and management of cirrhosis
四.【Colon cancer】
Chief complaint: Body weight loss for ( ) kg in ( duration)
Present illness:
This XXX-year-old woman has a history of 1.______; 2.______; 3.______. She complained of weight loss of XXX kg for XXX days/weeks/months with [associated symptoms: fever/chills/ anemia/ nutrient status/ stool pattern/ bloody stool/ dizziness/ SOB/ abdominal pain/ appetite/ bowel habit change/ constipation/ diarrhea]. Her abdominal examination showed [palpable mass/ DRE: ?/ abdominal fullness/ tenderness). Under the impression of colon cancer, she was admitted for further evaluation and treatment.
Past history:
1.Past medicalhistory:
# 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
# Herbal medication 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 (-)
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/m2
General appearance: well/fair/acute/chronic ill-looking
Catherization: s/p endotracheal tube intubation/CVP insertion/
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
no lymphadenopathy
Chest and lungs:
symmetric and free expansion, no use of accessory muscles
breath sounds–no rales/stridor/rhonchi/wheezing
Heart:
Regular/irregular heart beats, no murmurs, no S3 & S4
Abdomen:
Inspection –flat/bulging/distended, no operation scar, no striae,
no scratch marks, no bruises, no engorged veins
Auscultation –normo/hypo/hyper-active bowel sounds, no bruits
Palpation –no tenderness, no peritoneal signs (diffuse tenderness,
muscle guarding, rebound pain), no Murphy’s sign, spleen: impalpable,
Percussion –liver span: ( )cm over right middle clavical line, tympanic, no shifting dullness
Genitalia & digital rectal examination: no hemorrhoids, no palpable mass, normal anal tone,no blood stained on glove
Extremities:
warm/ cold, no pitting edema, no deformity
no flapping tremor
no loss of pulsation
Muscle power: RUE-grade ; LUE-grade
RLE-grade ; LLE-grade
Neurological:
no focal neurological deficits.
Laboratory and image data:
Impression: conlon cancer
Plan:
Diagnostic plan
-Colonosopy examination for tissue proof or lower GI series
-Abdominal CT for tumor staging
-Check CEA, albumin
Therapeutic plan>
-consult GS if resection is indicated, or consult oncologist for CCRT
- If not resection, consider chemotherapy
-If advanced stage, discuss hospice care to patient and family.
-Nutrient support
-NPO if complete obstruction.
<Educational plan>
-Consult dietitian.
-Educate patient about causes, complications, and management of bleeding/ obstruction
五.【Hepatoma】
Chief complaint: General weakness for XXXX days/weeks/months
Present illness:
This XXX-year-old woman has a history of 1.______, 2.______; 3.______. She complained of general weakness for XXX days/weeks/months with [associated symptoms: fever/chills/ anemia/ jaundice/ conscious status/ nutrient status/ urine output/ stool pattern/ skin lesions/ bleeding tendency/ dizziness/ SOB/ abdominal pain/ appetite/ bowel habit change/ body weight loss or not]. His abdominal examination showed [shifting dullness/ hepatomegaly/ splenomegaly/ jaundic/ lymphadenopathy]. Abdominal echo revealed a liver tumor, 5 mm in diameter in the [location]. Under the impression of hepatoma, she was admitted for further evaluation and treatment.
Past history:
1.Past medicalhistory:
# 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
# Herbal medication used: denied
# Occupation: ?
# Travel history: denied
# Animal exposure history: denied