CC:
Past history:
Personal history: alcohol(-), betel nut(-), cigarette(+): PPD for years, quit for years
Family history:
Location：位置
Quality：發作型態
Quantity/time course：發作歷時長短
Onset mode：疾病發作的型態或發作模式
Precipitating factors：環境或誘發因素
Exaggerating/exacerbating factors：加重因素
Relieving factors：緩解因素
Accompanying/associated symptoms：伴隨症狀
arrhyth-mia
rhino-rrhea
dia-rrhea
Consciousness: clear
HEENT: no anemic/pale conjunctiva, no icteric sclera, no tonsillar enlargement
CHEST: symmetric expansion, breath sounds: clear, no rales, no wheezing
HEART: regular heart beat, no murmur
ABDOMEN: flat and soft, normo-active bowel sound, no tenderness or rebounding pain, absent shifting dullness, Murphy's sign(-)
EXTREMITIES: no deformity, joint movement free
SKIN: normal turgor and color, no pitting edema, no petechia or ecchymosis
留言列表
