---
tags: Medical
---
# 常用範本

## History
### 一般
Chief complaint:

Allergy: nil
Past history:
### Injury
Chief complaint:

Tetanus toxoid in recent 5 years:
COVID19 vaccination in recent 2 weeks:
Allergy: nil
Past history:
### Traffic accident
Chief complaint: Collide with car while riding motorcycle just now

Denied head trauma, ILOC, vomiting, dizziness
Denied chest pain, abdominal pain, dyspnea

Tetanus toxoid in recent 5 years:
COVID19 vaccination in recent 2 weeks:

Allergy: nil
Past history:
## PE
Pupil: 3+/3+
HEENT: grossly normal
Neck: supple, jugular vein enlarged (-)
Chest: bilateral clear breathing sounds, symmetrical
Heart: regular heart beats
Abdominal: soft, flat, no tenderness, normoactive bowel sounds, rebounding(-), guarding(-)
Extremities: freely movable, no pitting edema
Back: CV angle knocking pain(-)

NE: no focal neurological sign, intact EOM, no nystagmus, no diplopia, no facial palsy, no tongue deviation Finger-nose-finger: normal, Muscle power: 5/5
## MBD
Symptom improved
No neurologic sign
No chest pain nor dyspnea
No abdominal pain

MBD with OPD f/u
Well educate patient possible risk and prognosis
Informed patient return to ER if symptoms aggrevate
患者自行掛號
## 診斷書
### 普通
病患因上述原因，於民國111年04月22日至急診求治，於同日出院，宜休養數日並門診續追蹤治療(以下空白)
### 縫合/手術
病患因上述原因，於民國111年04月22日至急診求治，並接受傷口縫合手術治療，於同日出院，宜休養數日並門診續追蹤治療(以下空白)
### OHCA

## Echo
### Abdominal echo
No ascites
No GB stone or cholecystitis
No Hydronephrosis
No aortic aneurysm
### Chest echo
No pleural effusion
No pericardial effusion
Normal aortic root diameter
Normal lung sliding
### E-FAST
No pleural effusion
No pericardial effusion
No ascites in Morrison's pouch, splenorenal fossa, Cul-de-sac
No obvious liver laceration or kidney laceration
Normal lung sliding