医院病历汇报通用模板.pptxVIP

医院病历汇报通用模板XXX大学附属上海浦东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6.41×109/L血红蛋白141g/L

生化白蛋白39.0g/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

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X-ray64岁，男性，既往体健进行性吞咽困难1月吸烟史，吸烟指数800病理诊断明确FEV13.04L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