医院病历汇报通模板病例汇报某年度汇报工作总医疗报告通用模板课件.pptx
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- 医院 病历 汇报 模板 病例 某年 工作 医疗 报告 通用 课件
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1、医院病历汇报通用模板xx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 6.41109/L 血红蛋白 141g/L生化白蛋白39.0g
2、/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-rayThere are many variations of passages of lorem ipsum available,but the majority have suffered alteration in some form,by injected humour randomized words which dont look even slightly,There are many var
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6、our randomized words which dont look even slightly.Blood Pressure ControlThere are many variations passages of The lorem ipsum available majority have suffer alteration,ipsum available majority have suffered alteration There are many The of variations passagesKeyword HereX-ray64岁,男性,既往体健进行性吞咽困难1月吸烟史
7、,吸烟指数800 病理诊断明确FEV1 3.04L 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FEV1 3.04L 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
8、预计值 50.5%FEV1 3.04L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%FEV1 3.04L占预计值 129.6%There are many variations of passages of lorem ipsum available,but the majority have suffered alteration in some form,by injected humour randomized words which dont look even slightly.There are many vari
9、ations of passages of lorem ipsum available,but the majority have suffered alteration in some form,by injected humour randomized words which dont look even slightly.There are many variations of passages of lorem ipsum available,but the majority have suffered alteration in some form,by injected humou
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12、.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FEV1 3.04L 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There are many variations passages of lorem ipsum available majority have suffered alteration.Keyword HereThere are many variations passages of lorem ipsum available majority have suffer
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