骨科标准病历范本-奇美医院.DOC

骨科標準病歷範本 一.【ACL】 Chief Complaint: Lt. knee pain with sensation of giving way for at least 2 years. Present Illness: This 27-year-old male patient is a soccer player. He injured his Lt. knee joint in a match some 2 years ago. There was immediate swelling in the joint and it lasted for a month. Since then, he frequently has a catching sensation in the joint with pain felt. A frequent giving way sensation was also felt. He had an MRI exam. done at Chang-Gung hospital which showed tear of the ACL. The patient came to our OPD. Physical exams led to the impression of Lt. knee ACL and med. meniscal tear and the patient was admitted to our ward for surgical intervention. Past History: 1.DM:- 2.Hypertension:- 3.Gout:- 4.Operation:- 5.Drinking:- 6.Smoking:- 7.Betle Nut:- Allergy:- Family History: Non-contributory 1.DM: Father:- Mother:- 2.Hypertension: Father:- Mother:- 3.Gout: Father:- Mother:- 4.other systemic disease:- Review of Systems: General appearance: fever (-), anorexia (-), body weight loss (-) Head and Neck: headache (-), sorethroat (-), rhinorrhea (-), blurred vision (-) Chest: chest pain (-), dyspnea (-), cough (-) hemoptysis (-), sputum (-) Abdomen: vomiting (-), diarrhea (-), flank pain (-), constipation (-), stool incontience (-) GU/GYN: dysuria (-), hematuria (-), nocturia (-), urinary incontience (-) Physical Examinations: Skin:normal tension, not dehydrated Consciousness:clear, alert Head: no trauma, no scar. Pupils: Isocoric, light reflex:+, prompt Conjunctiva: not pale. Sclera: not icteric. Neck: Supple, no LN is palpable Chest: Symmetric expansion, breathing sound is clear Heart: regular heart beat. No gallop. No bruit. No murmur. Abdomen; Flat, Solt, liver and spleen are not palpable no muscle guarding, no rebounding pain, no palpable mass, bowel sound: acoustic, normoactive Local findings: Rt Lt Genu Varum: - - Range of motion: