[心得]馬偕神內, 董一鋒學長病歷教學

93-12-05 晚間於淡水馬偕神經內科53病房,
董一鋒學長教我如何寫病歷, 以下為整理學長所教與自己心得:

1. Chief complaint: 病人來就診"最主要"的原因, 常是一句話
   
   
2. Present illness: 如何分段落?
   
   1. 基本資料, 與此次病程相關之重要underlying disease
      
      • 開頭: According the patient and his son's statement,...
   2. 此次病程描述, 注意要依時間順序
      
      • 開頭: On 93-12-02,...
   3. 來院至今(通常是在急診)所做之處理, findings + survey +treatment
      
      • 開頭: At ER,...
   4. 病人沒有的相關重要症狀, 於最後整理在一起比較清楚
      
      • 開頭: Through the course, there were no...
   5. 到目前, 你強烈懷疑病人有什麼問題, 而把病人收住院
      
      • 開頭: Under the impression of ..., he was admitted to our ward for further evaluation and treatment(management).
   
   
3. Past medical history: 記載較完整或與此次病程較不相關之病史, 通常包括(馬偕版):
   
   1. Allergy: drug, food
      
   2. Trauma, OP, Hospitalization
      
   3. Other systemic disease:
      
      • DM, HTN, Hyperlipidemia
        
      • Hepatitis B virus(HBV), Hepatitis C virus(HCV)...
        
      • CVA, CAD, CHF, Liver cirrhosis, Uremia,...
   4. Personal health habits:
      
      • Smoking, Alcohol, Betel nut
        
      • Traveling history, Animal contact
        
      • Current medication
        
      • Illegal drugs
   
   
4. Social history: 教育程度, 職業等
   
   
5. Family history: 記載 年齡, 健康狀況(疾病), 死因
   
   
6. Review of systems: 此處記載舊有(長期一直有)之 symptoms/signs, 以玆與本次之 present illness 與 physical examination 做比較
   
   
7. Physical examination: 此處記載本次理學檢查結果, 記得一開始要紀錄 TPR, BP, level of consciousness(GCS), body weight,...
   
   
8. Problems and Plans: 一個 problem 對應一 plan