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PHỤ LỤC 1: PHIẾU THU THẬP THÔNG TIN BỆNH NHÂN



MẪU BỆNH ÁN NGHIÊN CỨU

Mã hồ sơ B.án:



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Số :



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Hành chính

Họ và tên bệnh nhân: ………………………………...……………….

Tuổi: ……………… Giới:……… Nghề nghiệp:……………………….

Địa chỉ:…………………………………………………………………..

Liên hệ: ………………………………………SĐT ……………………



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1.

2.

3.

4.



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Ngày khám/vào viện:



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II. Chuyên môn

1. Lý do khám/vào viện:………………………………………

2. Hỏi bệnh

a. Bản thân : VKDT : Thời gian bị bệnh: ………… năm



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Điều trị hỗ trợ



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 Không.

 Không liên tục.

 Liên tục.



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Điều trị cơ bản:



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 Corticoid

 Khơng

 Có

 Liều thấp (<10mg)

 Liều cao (>10mg)

 Thuốc giảm đau NSAID

 Khác:

…………………………………………………………………………………

………………………………………………………………………………



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Bệnh kèm theo:



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 Khơng

 Có



Nội khoa: ……………………………………………………………………



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Ngoại khoa……………………………………………………………………

3. Khám bệnh

Toàn trạng:

 Mạch: ………ck/phút



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 t▫: ……oC

 HA: ….........mmHg



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 Nhịp thở: …….. lần/phút



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Thang điểm đau VAS:

 1-4 (đau nhẹ)

 5-7 (đau vừa)

 >7 (đau nặng)



BMI: ……………



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Cân nặng: ………..kg Chiều cao:………..cm



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Hội chứng giả Cushing



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 Khơng

 Có

Biểu hiện: ………………………………………………………….



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Khả năng đi lại/ hoạt động : ……………………………………………..

Cứng khớp buổi sáng:……………………….



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Biến dạng khớp : có  khơng 



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