医生病例分析完整模板

医院病历汇报通用模板办图网大学附属上海浦东医院病例汇报年度汇报工作总结医疗报告病人病史基本资料病人资料性别：

男年龄：64岁身高：186cm体重：58kg

进行性吞咽困难1月。近半月来症状进行性加重，现仅能进流质饮食。体重下降5Kg。无胸痛，无腹痛，无咳嗽，无呕血黑便，无声音嘶哑。无系统疾病，无慢性病史。无胸腹腔手术史。吸烟40年，日均20支，已戒2周。无大量饮酒史。既往个人史体格检查一般情况较好轻度脱水，营养不良外貌全身浅表淋巴结未及肿大胸廓对称，双肺呼吸音清，未及啰音。腹软，未及压痛，未及包块，肝脾未及。血常规白细胞6.41×109/L

血红蛋白141g/L生化白蛋白39.0g/L前白蛋白0.19g/L白蛋白39.0g/L前白蛋白0.19g/L乙肝免疫学Anti-HBs、Anti-HBe、Anti-HBc阳性抗原均阴性化验检查凝血机能基本正常肿瘤相关标志物正常X-rayTherearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon'tlookevenslightly,Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon'tlookevenslightly.BloodPressureControlTherearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon'tlookevenslightly,Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon'tlookevenslightly.BloodPressureControlX-rayTherearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon'tlookevenslightly,Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon'tlookevenslightly.BloodPressureControlTherearemanyvariationspassagesofTheloremipsumavailablemajorityhavesufferalteration,ipsumavailablemajorityhavesufferedalterationTherearemanyTheofvariationspassagesKeywordHereX-ray64岁，男性，既往体健进行性吞咽困难1月吸烟史，吸烟指数800病理诊断明确FEV13.04L占预计值129.6%FEV1%FVC占预计值95.90%MVV占预计值97.0%TLCO占预计值50.5%内镜检查内镜所见：胃镜下观察：距门齿约35cm始可见食管黏膜不规则隆起，环腔生长，致管腔狭窄，无法进镜。EUS扫查：上述病变不均匀低回声，侵及食管壁全层，各层间结构消失，部分浆膜层结构消失。检查结果表浅胃粘膜轻度慢性炎中度肠化送检组织内见鳞状细胞癌浸润病理诊断明确FEV13.04L占预计值129.6%FEV1%FVC占预计值95.90%MVV占预计值97.0%TLCO占预计值50.5%肺功能TLCO占预计值50.5%FEV13.04L占预计值129.6%FEV1%FVC占预计值95.90%MVV占预计值97.0%TLCO占预计值50.5%FEV13.04L占预计值129.6%Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon‘tlookevenslightly.Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon‘tlookevenslightly.Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon‘tlookevenslightly.Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon‘tlookevenslightly.Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon‘tlookevenslightly.Therearemanyvariationsofpassagesofloremipsumavailable,butthemajorityhavesufferedalterationinsomeform,byinjectedhumourrandomizedwordswhichdon‘tlookevenslightly.心脏彩超表浅胃粘膜轻度慢性炎中度肠化送检组织内见鳞状细胞癌浸润病理诊断明确FEV13.04L占预计值129.6%FEV1%FVC占预计值95.90%MVV占预计值97.0%TLCO占预计值50.5%其他Therearemanyvariationspassagesofloremipsumavailablemajorityhavesufferedalteration.KeywordHereTherearemanyvariationspassagesofloremipsumavailablemajorityhavesufferedalteration.KeywordHereTherearemanyvariationspassagesofloremipsumavailablemajorityhavesufferedalterationKeywordHereTherearemanyvariationspassagesofloremipsumavailablemajorityhavesufferedalterationKeywordHere01020304本病例特点10%20%40%60%此部分内容作为文字排版占位显示（建议使用主题字体）标题文本预设此部分内容作为文字排版占位显示（建议使用主题字体）标题文本预设此部分内容作为文字排版占位显示（建议使用主题字体）标题文本预设此部分内容作为文字排版占位显示（建议使用主题字体）标题文本预设结论标题文本预设此部分内容作为文字排版占位显示（建议使用主题字体）标题文本预设此部分内容作为文字排版占位显示（建议使用主题字体）标题文本预设此部分内容作为文字排版占位显示（建议使用主题字体）标题文本预设此部分内容作为文字排版占位显示（建议使用主题字体）感谢聆听Thanksforlistening11图网大学附属上海浦东医院首都医科大学附属北京X阳医院胸外科2038FOREIGNSTYLETEMPLATES工作报告年度总结医疗专业病例汇报简约时尚病例汇报模板主要目录FAST&TRUSTINTERVIEW壹叁贰Distinctivelyproductivatedynamictotallinkagevis-a-viscompetitiveplatforms.Professionallyunderwhelmintegratedinternalor"organic"Distinctivelyproductivatedynamictotallinkagevis-a-viscompetitiveplatforms.Professionallyunderwhelmintegratedinternalor"organic"Distinctivelyproductivatedynamictotallinkagevis-a-viscompetitiveplatforms.Professionallyunderwhelmintegratedinternalor"organic"肆六伍Distinctivelyproductivatedynamictotallinkagevis-a-viscompetitiveplatforms.Professionallyunderwhelmintegratedinternalor"organic"Distinctivelyproductivatedynamictotallinkagevis-a-viscompetitiveplatforms.Professionallyunderwhelmintegratedinternalor"organic"Distinctivelyproductivatedynamictotallinkagevis-a-viscompetitiveplatforms.Professionallyunderwhelmintegratedinternalor"organic"MAINCONTENT首都医科大学附属北京X阳医院患者：男年龄：64岁身高：156cm体重：58kg

首都医科大学附属北京X阳医院进行性吞咽困难1月。b.近半月来症状进行性加重，现仅能进流质饮食。c.体重下降5Kg。d.无胸痛，无腹痛，无咳嗽，无呕血黑便，无声音嘶哑。病人资料-病人病史FAST&TRUSTPatientinformation-PatienthistoryPatientinformation-PatienthistoryPast,personalhistory首都医科大学附属北京X阳医院体重下降5Kg。AND近半月来症状进行性加重，现仅能进流质饮食。AND无胸痛，无腹痛，无咳嗽，无呕血黑便，无声音嘶哑。END进行性吞咽困难1月START既往、个人史FAST&TRUSTPast,personalhistoryPhysicalexamination首都医科大学附属北京X阳医院淋巴系统BD胸廓对称，双肺呼吸音清，未及啰音C全身浅表淋巴结未及肿大A基本情况属于稳定基本轻度脱水，营养不良外貌状态胸腔体格检查FAST&TRUSTPhysicalexaminationLaboratorytests–bloodroutine首都医科大学附属北京X阳医院

血常规：白细胞6.41×109/L

血红蛋白141g/L血常规FAST&TRUSTRoutinebloodtest

血常规：白细胞6.41×109/L

血红蛋白141g/LLaboratorytests-biochemistry首都医科大学附属北京X阳医院白蛋白前白蛋白球蛋白血脂前白蛋白0.19g/L球蛋白20-35g/L白蛋白39.0g/L总胆固醇:2.8～5.17mmol/L、甘油三酯:0.56～1.7mmol/L、胆固醇脂:2.8～5.17mmol/L化验检查-生化FAST&TRUSTLaboratorytests-biochemistryLaboratorytests-HepatitisBimmunology首都医科大学附属北京X阳医院乙肝免疫学：Anti-HBs、Anti-HBe、Anti-HBc阳性，抗原均阴性化验检查-生化FAST&TRUSTLaboratorytests-biochemistryLaboratorytests-coagulationfunction-tumor-relatedmarkers首都医科大学附属北京X阳医院凝血机能凝血机能基本正常肿瘤相关标志物肿瘤相关标志物正常自定义添加区域自定义添加区域自定义添加区域化验检查-凝血机能-肿瘤相关标志FAST&TRUSTLaboratorytests-coagulationfunction-tumor-relatedmarkersX-光检查-胸片Herendlesspatiencemadeherthebestnurseinthehospital.首都医科大学附属北京X阳医院X-rayexamination;首都医科大学附属北京X阳医院正常分数：65%结论：具体结论具体分析注：胸部X线检查：主要用于肺炎行实变、纤维化、钙化、肿块、肺不张、肺间质病变、肺气肿、空洞、支气管炎症及扩张、胸腔积液、气胸、胸膜肥厚粘连、纵膈肿瘤、心脏、血管性态、乳房肿块诊断。X-光检查-胸片FAST&TRUSTX-rayexamination;X-rayexamination;首都医科大学附属北京X阳医院正常分数：65%结论：具体结论具体分析注：胸部X线检查：主要用于肺炎行实变、纤维化、钙化、肿块、肺不张、肺间质病变、肺气肿、空洞、支气管炎症及扩张、胸腔积液、气胸、胸膜肥厚粘连、纵膈肿瘤、心脏、血管性态、乳房肿块诊断。X-光检查-胸片FAST&TRUSTX-rayexamination;Microscopicexamination首都医科大学附属北京X阳医院正常分数：XX%结论：具体结论具体分析注：在为患者检查的时候，传统的方式经常会为病人造成痛苦，而耳鼻喉内窥镜检查时病人可以坐位，也可以半卧位，医生将耳鼻喉内窥镜伸入病人口腔、耳腔、鼻腔内。镜下检查FAST&TRUSTMicroscopicexaminationEndoscopy首都医科大学附属北京X阳医院正常分数：XX%结论：具体结论具体分析注：随着现代医学技术的发展，内镜作为医生眼、手的延伸，已经达到了“无孔不入”的境界。通过内镜检查，能对下述疾病进行诊断：肝、胆、胰腺管道系统的良、恶性病变；腹腔脏器的良、恶性病变。内镜检查FAST&TRUSTEndoscopy肺功能Pulmonaryfunction首都医科大学附属北京X阳医院FEV13.04L占预计值129.6%Loremipsumdolorsitat,consecteturadipiscingelit.Aliquamtinciduntan..MVV占预计值97.0%Lremipsumdolorsitat,consecteturadipiscingelit.Aliquamtinciduntan..TLCO占预计值50.5%Loremipsumdolorsitat,consecteturadipiscingelit.Aliquamtinciduntan..结论：CONCLUTION通气功能正常，弥散量中度降低。FEV13.04L占预计值129.6%Loremipsumdolorsitat,consecteturadipiscingelit.Aliquamtinciduntan..MVV占预计值97.0%Lremipsumdolorsitat,consecteturadipiscingelit.Aliquamtinciduntan..肺功能FAST&TRUSTPulmonaryfunction心脏彩超Echocardiography首都医科大学附属北京X阳医院左室射血分数：65%结论：心内结构未见明显异常注：心脏彩超是唯一能动态显示心腔内结构、心脏的搏动和血液流动的仪器，对人体没有任何损伤。心脏探头就像摄像机的镜头，随着探头的转动，心脏的各个结构清晰地显示在屏幕上。心脏彩超FAST&TRUSTEchocardiography其它Others首都医科大学附属北京X阳医院head下肢静脉超声未见血栓形成Electrocardiogram心电图：大致正常Underthevein全身骨扫描、头部CT未见肿瘤转移Physicaltestindicatorsarenormalornot？writeyourrelevanttexthereSedutperspiciatisundeomnisistenatuserrorsitvoluptatemaccusantiumnyangpentingbaraka