初診結(jié)構(gòu)化病歷附有答案

PCOS初診結(jié)構(gòu)化病歷[復(fù)制]多囊卵巢綜合征（PCOS）門診專病結(jié)構(gòu)化病歷1.編號(hào)：[填空題]*_________________________________2.姓名：[填空題]*_________________________________初診信息表一、一般情況3.姓名：[填空題]_________________________________4.年齡：[填空題]*_________________________________5.電話：[填空題]*_________________________________6.就診卡號(hào)[填空題]*_________________________________7.編號(hào)[填空題]*_________________________________8.首診日期[填空題]*_________________________________9.首診醫(yī)生[填空題]*_________________________________10.主訴[填空題]*_________________________________11.現(xiàn)病史[填空題]*_________________________________既往病史12.出生情況[多選題]*□胎兒生長受限□巨大兒□低體重兒□早產(chǎn)兒□其他_________________*13.肝臟疾病史[單選題]*○無○有_________________*14.腎臟疾病史[單選題]*○無○有_________________*15.血栓史[單選題]*○無○有_________________*16.乳腺疾病史[單選題]*○無○有_________________*17.血液系統(tǒng)疾病史[單選題]*○無○有_________________*18.內(nèi)分泌病史[單選題]*○無○有_________________*19.手術(shù)史[單選題]*○無○有_________________*20.住院史[單選題]*○無○有_________________*21.既往病史—其他：[填空題]_________________________________22.家族遺傳史[單選題]*○無○有_________________*二、月經(jīng)與避孕23.初潮年齡（歲）[填空題]_________________________________24.初潮后3年內(nèi)月經(jīng)情況[填空題]_________________________________25.末次月經(jīng)（LMP）[填空題]_________________________________26.前次月經(jīng)（PMP）[填空題]_________________________________27.平素月經(jīng)周期（天）[填空題]_________________________________28.平素月經(jīng)經(jīng)期（天）[填空題]*_________________________________29.有無性生活[單選題]*○無性生活○有性生活30.孕產(chǎn)史（次）[矩陣文本題]*G________________________P________________________順產(chǎn)________________________剖宮產(chǎn)________________________人流________________________自然流產(chǎn)________________________宮外孕________________________引產(chǎn)________________________31.最近6個(gè)月內(nèi)有無生育計(jì)劃[單選題]*○無○有（幾個(gè)月內(nèi)）_________________*32.月經(jīng)異常情況[多選題]*□月經(jīng)稀發(fā)（月經(jīng)周期＞35天）□月經(jīng)不規(guī)律□月經(jīng)頻發(fā)（月經(jīng)周期＜21天）□經(jīng)期過短（＜3天）□經(jīng)量過少（自我感覺）□痛經(jīng)VAS評(píng)分（0～10分）_________________*□閉經(jīng)□不規(guī)則子宮出血□經(jīng)期延長（＞7天）□經(jīng)量過多□經(jīng)間期出血□其他補(bǔ)充_________________*33.目前避孕方式[多選題]*□未避孕□避孕套□復(fù)方短效口服避孕藥□宮內(nèi)節(jié)育器（銅環(huán)等）□皮埋□左炔諾孕酮宮內(nèi)緩釋系統(tǒng)□自然避孕（安全期）□緊急避孕藥□輸卵管結(jié)扎□其他_________________*三、不良嗜好34.您現(xiàn)在或既往吸煙？[單選題]*○現(xiàn)在吸煙（支/天）_________________*○從不吸煙○曾經(jīng)吸煙已經(jīng)戒煙35.您在工作單位或家里經(jīng)常被動(dòng)吸煙嗎？[單選題]*○是○否36.其他不良嗜好[填空題]_________________________________37.四、體格檢查[矩陣文本題]*血壓收縮壓（mmhg）________________________血壓舒張壓（mmhg）________________________身高（m）________________________體重（kg）________________________BMI（kg/m2）________________________腰圍（cm）________________________臀圍（cm）________________________腰臀比________________________高雄體征篩查38.痤瘡[單選題]*○無○有（補(bǔ)充描述，如經(jīng)前加重/伴皮脂溢等）_________________*39.有痤瘡[單選題]*○輕度（I級(jí)）：僅有粉刺○中度（II級(jí)）：有炎性丘疹○中度（III級(jí)）：出現(xiàn)膿皰○重度（IV級(jí)）：有結(jié)節(jié)，囊腫依賴于第38題第2個(gè)選項(xiàng)40.多毛[多選題]*□無□有無胸毛_________________*□3個(gè)部位mF—G評(píng)分（分）_________________*□9個(gè)部位mF-G評(píng)分（分）_________________*□乳暈、臍部周圍可見粗毛41.有無自我治療，如脫毛等[單選題]*○無○有_________________*依賴于第40題第2;3;4;5個(gè)選項(xiàng)9個(gè)部位（上唇，下頜，前胸，上腹，下腹，上臂，大腿，背部，臀部）mF-G評(píng)分＞4分，或上唇，下腹，及大腿內(nèi)側(cè)3個(gè)部位總和評(píng)分≥2分亦可診斷。乳暈，臍部周圍可見粗毛則高度懷疑多毛癥可能42.雄激素性脫發(fā)[單選題]*○無○有43.根據(jù)ludwig視覺評(píng)分，分級(jí)為[單選題]*○I級(jí)（輕度脫發(fā)）：頭頂冠狀區(qū)域頭發(fā)稀疏，保留1—3cm寬的前額發(fā)際線○II級(jí)（中度脫發(fā)）：在I級(jí)的同一區(qū)域的頭發(fā)更為稀疏○III級(jí)（重度脫發(fā)）：患者頭頂冠狀區(qū)的頭發(fā)全部脫落依賴于第39題第1;2;3;4個(gè)選項(xiàng)44.有無[多選題]*□貧血貌□黑棘皮征□泌乳□滿月臉□其他陽性體征_________________*45.婦科檢查[單選題]*○有○無（月經(jīng)期未作婦科檢查）46.陰道檢查[矩陣文本題]外陰：________________________陰道：________________________宮頸：________________________子宮： ________________________雙附件：________________________其他：________________________依賴于第45題第1個(gè)選項(xiàng)47.肛查(不宜行陰道檢查女性)[矩陣文本題]外陰：________________________雙附件：________________________子宮：________________________其他：________________________五、輔助檢查建議項(xiàng)目48.血常規(guī)[矩陣文本題]*Hb（g/L）________________________正常________________________異常________________________其他________________________49.尿妊娠試驗(yàn)或血HCG檢查：[填空題]*_________________________________50.甲功[單選題]*○正?！甬惓?1.甲功[矩陣文本題]*TSH________________________FT4________________________FT3________________________其他________________________52.性激素及AMH[矩陣文本題]*月經(jīng)第幾天測(cè)性激素________________________FSH________________________ LH________________________E2  ________________________PRL________________________AMH________________________T ________________________游離睪酮(FT) ________________________性激素結(jié)合球蛋白(SHBG) ________________________游離雄激素指數(shù)(FAI):(FAI總睪酮(n= mol/L)x100/性激素結(jié)合球蛋白(nmol/L)________________________其他(雄烯二酮、脫氫表雄酮、硫酸脫氫表雄酮等)________________________月經(jīng)周期第幾天測(cè)P________________________P________________________53.盆腔超聲[矩陣文本題]*月經(jīng)周期第幾天查 ________________________子宮大小________________________內(nèi)膜厚度cm(單層)  ________________________雙附件 ________________________卵巢多囊性改變（有或無）________________________其他________________________選查項(xiàng)目54.代謝指標(biāo)的評(píng)估[矩陣文本題]*FPG________________________FINS________________________OGTT________________________HOMA-IR=FPG(mmol/L)*FINS(μU/ml) /22.5=________________________55.血脂：[矩陣文本題]*正常或異常________________________甘油三酯________________________膽固醇________________________高密度脂蛋白________________________低密度脂蛋白________________________56.肝功：[單選題]*○正?！甬惓?7.肝功能[矩陣文本題]*白蛋白________________________谷草轉(zhuǎn)氨酶 ________________________谷丙轉(zhuǎn)氨酶________________________其他________________________58.腎功[單選題]*○正?！甬惓?9.腎功能[矩陣文本題]*尿素________________________尿酸________________________肌酐________________________其他________________________60.乳腺B超：[單選題]*○正?！甬惓?1.乳腺B超：BI-RADs分類[單選題]*○0○1○2○3○4○5○6○其他依賴于第60題第2個(gè)選項(xiàng)62.人體成分：[矩陣文本題]*人體成分測(cè)定體脂肪含量Kg________________________骨骼肌含量Kg ________________________ 基礎(chǔ)代謝率kcal________________________63.肥胖評(píng)估：[單選題]*○正?！鸬腕w重○超重○肥胖○嚴(yán)重肥胖64.心理評(píng)估：（分）[矩陣文本題]*PHQ-9   ________________________GAD-7 ________________________SDS________________________SAS