常用醫令－honorvip

S: Lower abdominal pain for 1 week.
Foul odor with discharge were noted in 5 days.
Itching with discharge were noted in 5 days.
spotting off and on for 1 week
PH:N.P., No allergy history
F.H.: N.P.
GYN:P0 , LMP:
PV:
vag: discharge: Whitish with yellowish
Cervix: erosion(+), lifting pain (+)
Uterus: tenderness(+), AVF, N/S
Adnexae: N.P.

Sonography:
Uterus: AVF, Myomatous nodule was noted.
Adnexa: Adnexal cyst was found.

S: for PAP smear
PH: N.P.
F.H.: N.P.
PV:
vag: discharge: scanty
Cervix: erosion(-), lifting pain (-)
Uterus: tenderness(-), AVF, N/S
Adnexae: N.P.

S: For ANC, EDC:
PH: NP
FH: NP
sonography:
Vertex, FHB(+), placenta: fundal, grade 2, AF: mod.
S: For CD
wound: adaptation well, no oozing
E-P wound: adaptation well
Lochia: moderate

Sonography:
Uterus: AVF, Myomatous nodule was noted.
Adnexa: Adnexal cyst was found.

S: Postpartum checkup
PH: NP
FH: NP
Uterus: contraction well
Lochia: moderate
Wound: adaptation well

*診斷書-------
妊娠19週, 先兆性流產。﹝以下空白﹞
宜在家休息兩星期, 以利病情。﹝以下空白﹞

子宮肌瘤. 左側卵巢腫瘤(空白)
病患於94年元月17日住院接受子宮及左側卵巢切除術,於94年元月22
日出院.(空白)

於96-2-6 做女性結紮(兩側輸卵管結紮術)。﹝以下空白﹞

*門診診斷碼------
Rape E960.1 診斷書023-A
PCOD: 256.4
諮詢V65.40
睡眠障礙780.50
痛經625.3
頭痛784.0
眩暈780.4
肌痛 729.1
腰痛 724.2
睡眠障礙780.9
乳腺炎 611
營養不良 263
疣 078.11
尿失禁625.6
子宮頸瘜肉622.7
子宮頸縻爛 622.0
巴氏腺616.3
不孕 628.7
胎死腹中 656.4
IUGR 656.5
妊娠嘔吐 643.90
唐氏症 655.93
產前出血 641產前出血 666

*住院診斷碼------
Breech 652.23 Transverse 652.33 Face 652.43
Previous C/S 654.20 Fetal Distress656.30 CPD 653.40
Prolonged labor662.10, 662.00 Twin 651.00
Placental previa 641.00 Abruptio placenta 641.20
Pre-eclampsia 642.4
Pelvic adhesion 614.6 Placental retention 667.00

*實驗碼-----
培養13007c -- culture
病理 25004C
自費抹片15017c, 55012c
Herpes: IgG(14005C) IgM(14052B)
披衣Chlamydia: 12107C
乳房 cytology: 15001C其他項
自費GBS: 13007-20 (200.-)
自費HPV-DNA: 12077B-1 (1600.-)
孕婦AIDS: E3001C
外籍產檢0837
唐氏症12022B, down
妊娠糖尿OGTT

NST 18013C
超音波19003C
內診55011C, 55021C

子宮輸卵管攝影33029B 通氣29022C 陰道鏡28028C
骨密BMD 33064B
骨盆攝影PELVIMETRY 32024C (653.10)
KUB -- 32006c
Chest PA -- X01
abdomen standing -- X20
CT Scan -- 33072B
mammography -- 33005B

*手術碼------
結紮659.9, 0192
疣電燒55008C 冷凍55003C, 55013C 電燒55007C
子宮頸瘜肉切除80207C (622.7)
子宮頸切片55001C
子宮內膜切片55002C
診斷性D&C 80401C D&C81006C, 81007C(69.51)
避孕器55020C, 55018C (662.4),
拿避孕器55006B
會陰引流79601C 巴氏腺79802C(616.3)
陰道囊腫80002C 子宮頸出血55004C
CULDOCENTESIS 29023C
一般導尿47013C 換藥48012C, 48026C (674.34)
產前(後)出血 55015C(622)
CD 48026C 48012C
自費C/S 97014C (NT15188) 收費差額 97007A-1 (NT19098)
自費剖腹生產669.71 NSD 650
結紮659.9, 0192 (NT6500), 疣電燒55008C