初診結構化病歷附有答案

PCOS初診結構化病歷[復制]多囊卵巢綜合征（PCOS）門診專病結構化病歷1.編號：[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[填空題]*_________________________________7.編號[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.血液系統疾病史[單選題]*○無○有_________________*18.內分泌病史[單選題]*○無○有_________________*19.手術史[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、月經與避孕23.初潮年齡（歲）[填空題]_________________________________24.初潮后3年內月經情況[填空題]_________________________________25.末次月經（LMP）[填空題]_________________________________26.前次月經（PMP）[填空題]_________________________________27.平素月經周期（天）[填空題]_________________________________28.平素月經經期（天）[填空題]*_________________________________29.有無性生活[單選題]*○無性生活○有性生活30.孕產史（次）[矩陣文本題]*G________________________P________________________順產________________________剖宮產________________________人流________________________自然流產________________________宮外孕________________________引產________________________31.最近6個月內有無生育計劃[單選題]*○無○有（幾個月內）_________________*32.月經異常情況[多選題]*□月經稀發(fā)（月經周期＞35天）□月經不規(guī)律□月經頻發(fā)（月經周期＜21天）□經期過短（＜3天）□經量過少（自我感覺）□痛經VAS評分（0～10分）_________________*□閉經□不規(guī)則子宮出血□經期延長（＞7天）□經量過多□經間期出血□其他補充_________________*33.目前避孕方式[多選題]*□未避孕□避孕套□復方短效口服避孕藥□宮內節(jié)育器（銅環(huán)等）□皮埋□左炔諾孕酮宮內緩釋系統□自然避孕（安全期）□緊急避孕藥□輸卵管結扎□其他_________________*三、不良嗜好34.您現在或既往吸煙？[單選題]*○現在吸煙（支/天）_________________*○從不吸煙○曾經吸煙已經戒煙35.您在工作單位或家里經常被動吸煙嗎？[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（補充描述，如經前加重/伴皮脂溢等）_________________*39.有痤瘡[單選題]*○輕度（I級）：僅有粉刺○中度（II級）：有炎性丘疹○中度（III級）：出現膿皰○重度（IV級）：有結節(jié)，囊腫依賴于第38題第2個選項40.多毛[多選題]*□無□有無胸毛_________________*□3個部位mF—G評分（分）_________________*□9個部位mF-G評分（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個選項9個部位（上唇，下頜，前胸，上腹，下腹，上臂，大腿，背部，臀部）mF-G評分＞4分，或上唇，下腹，及大腿內側3個部位總和評分≥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ludwig視覺評分，分級為[單選題]*○I級（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（中度脫發(fā)）：在I級的同一區(qū)域的頭發(fā)更為稀疏○III級（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個選項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個選項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.尿妊娠試驗或血HCG檢查：[填空題]*_________________________________50.甲功[單選題]*○正常○異常51.甲功[矩陣文本題]*TSH________________________FT4________________________FT3________________________其他________________________52.性激素及AMH[矩陣文本題]*月經第幾天測性激素________________________FSH________________________ LH________________________E2  ________________________PRL________________________AMH________________________T ________________________游離睪酮(FT) ________________________性激素結合球蛋白(SHBG) ________________________游離雄激素指數(FAI):(FAI總睪酮(n= mol/L)x100/性激素結合球蛋白(nmol/L)________________________其他(雄烯二酮、脫氫表雄酮、硫酸脫氫表雄酮等)________________________月經周期第幾天測P________________________P________________________53.盆腔超聲[矩陣文本題]*月經周期第幾天查 ________________________子宮大小________________________內膜厚度cm(單層)  ________________________雙附件 ________________________卵巢多囊性改變（有或無）________________________其他________________________選查項目54.代謝指標的評估[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?；虍惓_______________________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________________________谷草轉氨酶 ________________________谷丙轉氨酶________________________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個選項62.人體成分：[矩陣文本題]*人體成分測定體脂肪含量Kg________________________骨骼肌含量Kg ________________________ 基礎代謝率kcal________________________63.肥胖評估：[單選題]*○正?！鸬腕w重○超重○肥胖○嚴重肥胖64.心理評估：（分）[矩陣文本題]*PHQ-9   ________________________GAD-7 ________________________SDS________________________SAS