肺癌电子文档病历模板精选.

入 院 记 录

现病史： 患者07年11月体检时发现右下肺占位，在***医院行穿刺活检提示右肺腺癌，在***医院行伽马刀治疗，后在外院行GP方案化疗2程，08年3月在我科行厄罗替尼治疗，09年3月出现胸部疼痛，CT提示右第4肋骨破坏，在我科行唑来膦酸治疗多次及中药治疗，此为再次唑来膦酸治疗入住我科，病程中患者一般情况尚可，无胸闷咳嗽，无咳血，纳可，眠佳，二便正常，近期无明显消瘦史。                                                                     

既往史： 否认药食物过敏史，既往有高血压病，糖尿病，前列腺增生慢性病史，无心脏病及外伤史，否认肝炎、结核等传染病史                                                                   

个人史： 否认疫区、疫水接触史，无冶游史                                                                   

月经、婚育史：适龄结婚，配偶及子女均体健                                                               

家族史： 否认家族遗传病史                                                                   

体 格 检 查

T：  ℃          P：  次/分         R：  次/分          BP：  mmHg

一般情况： 神志清楚，精神可，营养中等，步入病房，查体合作，对答切题                                                                          

皮肤黏膜： 全身皮肤、粘膜无明显黄染                                                                 

浅表淋巴结： 浅表淋巴结未触及明显肿大                                                               

头部及器官： 头颅无畸形，双瞳孔等大等圆，对光反射灵敏，耳、鼻、口无异常                                                                                    

颈部： 颈软，气管居中，甲状腺未触及肿大                                                                       

胸部： 胸廓对称，胸廓扩张度正常，语颤正常，双肺叩诊清，听诊呼吸音低，双肺未闻及明显的干湿啰音，右侧肋骨压痛可疑，心前区未见明显隆起，心尖搏动有力，心界向左下扩大，心率   次/分，律齐，各瓣膜未闻及明显杂音                                                                     

腹部： 腹软，平坦，腹壁静脉未见明显怒张，全腹无压痛及反跳痛，肝脾肋下未及，墨菲氏征阴性，肠鸣音不亢。                                                                     

脊柱和四肢： 脊柱无畸形，各椎体无压痛及反跳痛，四肢无畸形，双下肢无水肿                                                               

神经系统： 生理反射存在，病理反射未引出                                                                 

肛门和外生殖器： 未查                                                           

舌象和脉象： 舌红，苔薄黄，脉滑。                                                               

专科情况：  全身皮肤粘膜无明显黄染，浅表淋巴结未触及明显肿大，双肺呼吸音低                                                                

           未闻及干湿性啰音，右侧肋骨压痛可疑，KPS：80分。                                                                 

辅助检查： 暂缺                                                                 

                                  初步诊断：中医诊断：疾病诊断：肺癌             

                                                      证候诊断：痰湿蕴肺            

                                            西医诊断：肺癌伴骨转移                      

                                                      高血压病2级（高危组）

                                                      2型糖尿病            

                                                      前列腺增生                       

                                               医师签名：                     

                                                              年   月  日     

入院诊断：中医诊断：疾病诊断：                                                

                    证候诊断：                                                

          西医诊断：                                                          

                                                          医师签名：                  

                                                               年  月  日                 

2010年3月16日10时              首 次 病 程 记 录                                  

   患者李伟，系发现肺癌两年余入院。                                                                         

   患者07年11月体检时发现右下肺占位，在***医院行穿刺活检提示右肺腺癌，在***脑科医院行伽马刀治疗，后在外院行GP方案化疗2程，08年3月在我科行厄罗替尼治疗，09年3月出现胸部疼痛，CT提示右第4肋骨破坏，在我科行唑来膦酸治疗多次及中药治疗，此为再次唑来膦酸治疗入住我科，病程中患者一般情况尚可，无胸闷咳嗽，无咳血，纳可，眠佳，二便正常，近期无明显消瘦史。否认药食物过敏史，既往有高血压病，糖尿病，前列腺增生慢性病史，无心脏病及外伤史，否认肝炎、结核等传染病史，否认家族遗传史。                                                                                                                                                                         

   T：   ℃          P：  次/分         R：  次/分          BP：        mmHg

   神志清楚，精神可，营养中等，步入病房，查体合作，对答切题，全身皮肤、粘膜无明显黄染，浅表淋巴结未触及明显肿大，头颅无畸形，双瞳孔等大等圆，对光反射灵敏，耳、鼻、口无异常，颈软，气管居中，甲状腺未触及肿大，胸廓对称，胸廓扩张度正常，语颤正常，双肺叩诊清，听诊呼吸音低，双肺未闻及明显的干湿啰音，右侧肋骨压痛可疑，心前区未见明显隆起，心尖搏动有力，心界向左下扩大，心率   次/分，律齐，各瓣膜未闻及明显杂音，腹软，平坦，腹壁静脉未见明显怒张，全腹无压痛及反跳痛，肝脾肋下未及，墨菲氏征阴性，肠鸣音不亢，双下肢不浮，NS(-),舌红，苔薄黄，脉滑，KPS：80分。                                                                         

    辅助检查：                                                                

    暂缺                                                                         

    中医辨病辨证依据：                                                        

    据该患者望、闻、问、切四诊资料可以辩患者病为祖国医学中“肺癌”范畴，中医病机上认为患者由于正气亏虚，阴阳失调，六淫之邪乘虚而入，邪滞于肺，致肺气不输，宣降失司，津液不输，聚而成痰，留于肺中，渐成积块。                                                                         

    中医鉴别诊断：                                                            

     应于肺痨相鉴别，肺痨以干咳，消瘦，咯血为主，多伴低热，盗汗，系痨虫所致，具有传染性，经抗痨治疗有效。                                                                                                                                                                     

     西医诊断依据：                                                            

     1、患者系发现肺癌两年余入院。                                                                        

     2、病理：腺癌。                                                                                          

     3、神清，精神可，全身皮肤粘膜无明显黄染，浅表淋巴结未触及明显肿大，双                                                                

 肺未闻及干湿性啰音，右侧肋骨压痛可疑，KPS：80分。                                                                                                              

    西医鉴别诊断：                                                             

     1、肺结核：以干咳，消瘦，咯血为主，多伴低热，盗汗，具有传染性，抗结核治疗有效，痰中可找见抗酸杆菌。                                                                        

     2、肺炎：以胸疼，高热，咳嗽，咳痰常见，肺部可闻及明显湿啰音，抗感染治疗有效，痰中一般可找见致病菌。                                                                    

                                     入院诊断：                               

                                             中医诊断：疾病诊断：肺癌             

                                                      证候诊断：痰湿蕴肺            

                                            西医诊断：肺癌伴骨转移                      

                                                      高血压病2级（高危组）

                                                      2型糖尿病            

                                                      前列腺增生                      

  诊疗计划：                                                                   

   （1）、内科护理常规                                                                              

   （2）、二级护理                                                                              

   （3）、完善各项相关检查                                                                                

   （4）、西医予以对症处理                                                                          

   （5）、中医上予以患者祛湿化痰之剂                                                                            

  苏子12g         白芥子9g        莱菔子15g       陈皮10g                                                                                    

  半夏12g        茯苓10g          甘草 6g         生苡米30g                                                                                 

  白及 20g        龙葵15g       X5付（3.16-3.20                                       

  上方加水500ml，浓煎取汁300ml，分2次服用，每日一剂。                                                                            

   （6）、健康教育                                                                       

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