Gynecological medical records 1. The requirements for writing gynecological medical records refer to the requirements of general medical records, and pay attention to the following items: (1) medical history and past history, asking about the occurrence and development of main symptoms, the examination of onset and the whole process of treatment changes. 1. If the chief complaint is vaginal bleeding or abnormal menstruation, the age of menarche, previous menstrual cycles, amount and duration of bleeding, presence or absence of blood clots, degree of dysmenorrhea, occurrence time and changes should be recorded in detail; The last menstrual period, whether there are systemic symptoms, nosebleeds, skin purpura, etc. 2. For those who complain of increased leucorrhea, attention should be paid to the onset time, the nature, quantity, color and smell of leucorrhea, and whether there are any accompanying symptoms (such as pruritus vulvae, lower abdominal pain and urinary symptoms). ), and the relationship between vaginal discharge and menstruation and pregnancy. 3. If the chief complaint is abdominal mass, attention should be paid to the onset time, primary site, size, growth rate, activity, hardness and tenderness, menstrual changes, chronic or acute abdominal pain, bladder, rectum or chest compression symptoms, and should be differentiated from pregnancy, ascites and urinary retention. 4. For those who complain of abdominal pain, ask about the attack time, nature, degree, frequency, attack inducement or other symptoms (such as amenorrhea and early pregnancy reaction). ), the site of abdominal pain, whether there is metastasis, accompanied by symptoms (such as fever, vomiting, syncope, frequent urination, diarrhea, etc. ), treatment, and whether there is a history of attack or surgery in the past. 5. Patients who have not recovered from other special injuries should be briefly described in another paragraph of the current medical history. Past history of tuberculosis, appendicitis, goiter, gastrointestinal, heart, kidney and blood system diseases and exposure to harmful substances. If you have had surgery, you must know the name, function and reaction of narcotic drugs. Personal history 1. Menstrual history Age, duration and cycle of menarche, menstrual flow, presence or absence of blood clots and history of dysmenorrhea. Time of last menstruation and previous menstruation. 2. Marriage history, marriage age or remarriage age, and husband's health status. Infertility, you must know about sex life. 3. Pregnancy history, age of first pregnancy, number of pregnancies (including full-term delivery, premature delivery, abortion, induced abortion, number of existing children), and whether there are any abnormalities such as infection, dystocia and massive bleeding in each pregnancy. Have you used contraceptive measures, methods and effects in the last month of pregnancy, and are there any side effects or complications? Family history of hereditary or infectious diseases, such as malformation, hemophilia, albinism, hypertension, diabetes, cancer, tuberculosis, etc. (2) Physical examination 1. According to the order of physical examination, pay special attention to nutrition, development, hair distribution and density, whether the thyroid gland is enlarged, whether the breast is well developed and whether there is a lump. 2. Routine gynecological examination, including examination of the lower abdomen, vulva and voyeurism, double river needle, triple diagnosis or digital rectal examination. (3) Examination and other examinations 1. Routine examination of blood, urine and feces and other related examinations. 2. Patients should be checked for trichomonas vaginalis, fungi and cleanliness before taking off or before operation. Routine cervical cytology examination for married women over 30 years old. 4. ECG, ultrasound, X-ray, CT, etc. Inspection shall be carried out as required. Second, gynecological medical records take admission records as an example Lu Zhixiang, female, 40 years old, married, from Xiaoshan County, Zhejiang Province. Han nationality, a worker from Shanghai Oriental Kai Guanchang, now lives at No.2, Lane 0/00, Fengyang Road, Shanghai. Abdominal masses were found 1 year, which increased obviously in recent 3 months. He was admitted to hospital on1991-1-7. I declare and record it on the same day. Since 199 1 year 101October 20th, I have been admitted to XX Hospital for fever, stomach cold and lower abdominal pain, and my uterus has been examined to be enlarged like a fist. I was given anti-infective treatment. In the past three months, my consciousness has been obviously enhanced, and my hands and feet are swollen and my legs are swollen. In the last 2 months, frequent micturition, nocturia 4~5 times, clear color, no dysuria. So, I went to the internal medicine clinic of Huangpu District Central Hospital on September 12. After taking the medicine, the leg swelling subsided, but the abdominal distension remained. The overall situation in the future is still good. Menstruation increased in recent March, once every 20 ~ 25 days, lasting 7 ~ 10 days, with bright red color, blood clots and dysmenorrhea. Patients are usually in good health. When I was 3 years old, I got "measles" without complications; Denying the history of other acute and chronic infectious diseases. I was vaccinated when I was a child. In recent years, mild edema of the whole body often occurs, which can be subsided after taking diuretics. I have suffered from stomach trouble for several years, and I often feel sour and warm. No history of drug allergy was found. Born in Xiaoshan County, Zhejiang Province, I have been to Shanghai since I was a child. I have never been to other places, and I am addicted to alcohol and tobacco. My menstrual history is 18 (3 ~ 5/30) days, and I have no dysmenorrhea. The last menstrual period was 199 1 year 1 month 10 days, which lasted for 5 days. Last menstruation1991September 25th. Married at the age of 20, her husband was 48 years old, and died of "stomach cancer" in September this year. Three full-term children were born after marriage, and all the children lived. I had an abortion seven years ago and haven't given birth since (no contraceptive measures have been taken). Father is still alive. My mother/kloc-died of cervical cancer 0/0 years ago. Brothers and sisters 1 are alive and have no special medical history. Physical examination showed that the body temperature was 37.7℃, the pulse was 90 beats/min, the respiration was 20 beats/min, the blood pressure16/10.7 kpa (120/80 mmhg), the height 154cm, and the weight was 51. There is no yellow stain on the skin and sclera of the whole body, no swelling of superficial lymph nodes, normal development of facial features, round pupils, good response to light and small tonsils. The neck is soft and the thyroid gland is not enlarged. Chest symmetry, free movement, clear breathing sounds in both lungs. Heart rate is 90/ min, and the heart rhythm is consistent. You can smell the murmur of ⅰ ~ ⅱ degree contraction at the apex of the heart. The middle of the lower abdomen is slightly swollen, and a lump with a big head of a child can be felt in the lower abdomen of the navel. Irregular surface, tough texture, tender and firm. Liver and spleen do not touch. The bowel sounds are normal. The spine is normal, the limbs move freely, and there is physiological reflex. No pathological reflex was caused. Gynecological examination showed that the vulva developed normally, pubic hair was evenly distributed, labia majora and labia majora were symmetrical on both sides, and the old perineal laceration was second degree. The vagina has good extensibility, a small amount of yellowish secretion, smooth and hypertrophy of the cervix, and transverse fissure at the neck opening. The uterus border is unclear, and the mass almost occupies the whole pelvic cavity, inclines to the left, clings to the left pelvic wall, is hard and inactive, and reaches the lower abdomen higher than the pelvic cavity, which is about the size of a uterus after five months of pregnancy. The right side of the mass is slippery and the left side is obviously uneven. The left accessory was squeezed by the mass, the palpation was unclear, and the tenderness was+; The accessories on the right are thick and tender. Blood routine: red blood cell count is 4× 10. 12 & lt； /sup & gt； /L, hemoglobin 100g/L, white blood cell count 8.6×10 <
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Pediatric medical records
A, pediatric medical record writing requirements
(1) medical history
The content of medical history inquiry has been explained in detail in the general medical record, but the following special requirements for pediatrics should be paid attention to:
The personal medical history of newborns and infants should be recorded in detail. In addition to the current medical history, children of other ages can be simplified.
1. Fetus, perinatal condition, parity, parity, parity number; Production situation; Date of birth and birth weight. Whether there is suffocation, cyanosis, paralysis and deformity. Cry loudly or weakly. Whether there is bleeding and rash after birth, and how sucking power is. Pregnant women's health status during pregnancy, whether there are infectious drugs and history of injury. For newborns or those with related diseases, we should focus on asking.
2. Feeding human milk or artificial feeding (milk, milk content); Whether to feed regularly; Whether there is galactorrhea or vomiting, its nature and time. Increase food intake. When to wean, the current diet, whether there is a partial eclipse or picky eaters. Children under 2 years old should focus on asking questions.
3. When can you stand upright, laugh, sit alone, stand and walk? Dental time; When will I call my parents and say simple sentences? Whether family and school life can adapt; How is your academic performance? Children under 3 years old or children with developmental retardation should focus on asking.
4. Living habits, sleep time, activities, sleep and defecation.
Past medical history
1. Have you ever suffered from or been exposed to the following acute and chronic infectious diseases: measles, chickenpox, whooping cough, scarlet fever, mumps, meningitis, encephalitis, malaria, typhoid fever, hepatitis, tuberculosis, schistosomiasis, etc. And record the onset age, course of disease, complications and results. Pay attention to the history of intestinal parasites and the effect of deworming treatment.
2. The allergic history is mainly manifested by drugs (penicillin, streptomycin, etc. ), food (milk, fish, eggs, etc. ) or other allergic history.
3. Vaccination date and reaction of BCG, polio, pertussis, tetanus, measles, Japanese encephalitis, meningitis and hepatitis.
Family calendar
1. Parents' age, occupation and health status, whether close relatives are married, the number of births of children and mothers, and whether there is a history of abortion, premature birth, multiple births and hemolytic delivery of newborns.
2. If there are brothers and sisters, ask them about their age and health in order; If you die, record the cause of death. Whether each family member has hepatitis, tuberculosis, allergic diseases or related genetic history.
3. Family environment, family hygiene, whether the population is crowded, and who will take care of the children.
(2) Physical examination
For details, please refer to the medical admission records for physical examination requirements. Try to get the children's cooperation during the exam. The inspection sequence should be flexible. The principle is to check the parts that are easily affected by crying, such as the chest and abdomen, and then check the parts that are more irritating to children, such as the throat. Other non-emergency examinations and operations can be carried out after the child is slightly familiar with them. Pay attention to the following points when checking:
1. General measurements include body temperature, respiration, pulse, weight and blood pressure (under 3 years old, as appropriate), and body length, head circumference, chest circumference, abdominal circumference, sitting height and upper and lower volume are measured when necessary.
2. The general situation includes development, nutrition, posture, expression, spirit, consciousness, ability to respond to the surrounding environment, language and intellectual development, loud or weak crying, whether there is brain screaming, etc.
3. Hair color, baldness, head lice, skull deformity and skull softening. Whether the fontanel is closed, size, flatness, depression or uplift, and whether there is pulsation. Whether there is sebum overflow on the scalp. Pay attention to the tongue image and mucosal color of the mouth and pharynx.