肛肠科病历模板（Anorectal medical record template）.docVIP

肛肠科病历模板（Anorectal medical record template） Complained of perianal swelling and pain for 2 days History: 2 days before admission due to private patients, no obvious cause was found around the anus swelling, pain refused to press, no ulceration pus, no itching, no bleeding, no difficult defecation, nausea and vomiting, abdominal pain, diarrhea, cold fearless fever, without frequent micturition, urgency, dysuria and dysuria. Untreated. In todays visit to the hospital, the outpatient examination initially intended for perianal abscess, undergraduate. Chen anal abscess pain refused to press, no ulceration pus, no skin itching, since admission, spirit, sleep, diet, urine can, no significant change in body weight. Past history: hepatitis, tuberculosis, typhoid and deny the history of infectious diseases, denied hypertension, diabetes and other genetic disease, trauma surgery and blood transfusion history, denied drug history of food allergy, vaccination history is unknown. Personal history: born in the country of origin, no water contact history and long-term foreign history of living, living and working conditions in general, no toxic and radioactive substances contact history. Smokeless wine and other bad habits. Obstetrical history: no special. Family history: deny other members of the family have similar medical history, deny the hypertension, diabetes and other familial genetic, infectious diseases history. physical examination T:36.2 P:82 R:20 BP125/75mmHg C / min / min Sane, normal development, nutrient medium, acute pain had entered the ward, automatic position, check the answer to the question, cooperation. The whole body skin mucous membrane has no yellow stain, no bleeding point, no liver palm, spider nevus. Superficial lymph nodes are not enlarged. The head has no deformity, the features are regular, the bilateral pupils are round and round, sensitive to light, no secretions in the external auditory canal, normal hearing and no tenderness of the mastoid. No par