实习生大病历模板

住院病历姓名籍贯:性别出生地年龄常住地址民族单位职业入院时间年月日时婚况记录时间年月日时病史陈述者联系人及电话主诉__________________________________________________________________________现病史________________________________________________________________________既往史________________________________________________________________________系统回顾______________________________________________________________________个人史________________________________________________________________________过敏史________________________________________________________________________婚育史________________________________________________________________________家族史________________________________________________________________________体格检查体温T脉搏P呼吸R血压BP一般情况______________________________________________________________________皮肤及粘膜____________________________________________________________________淋巴结________________________________________________________________________头颅及其器官__________________________________________________________________颈部__________________________________________________________________________胸部胸廓_________________________________________________________________________肺脏视诊__________________________________________________________________________触诊__________________________________________________________________________叩诊__________________________________________________________________________听诊—__________________________________________________________________________心脏视诊__________________________________________________________________________触诊__________________________________________________________________________叩诊____________________________________________________________________________听诊____________________________________________________________________________周围血管______________________________________________________________________腹部望诊__________________________________________________________________________触诊__________________________________________________________________________叩诊__________________________________________________________________________听诊:外生殖器官:肛门直肠______________________________________________________________________脊柱四肢_______________________________________________________________________神经系统_______________________________________________________________________外科情况实验室及器械检查病历摘要（内科）初步诊断_______________________住院医师/实习医师。