เลขที่บัตรผู้ป่วย :
ชื่อ - สกุล (Name - Surname) :    
อายุ (Age) :   การวินิจฉัยโรค      ระดับผู้ป่วย  
 
 

การตรวจร่างกาย (PE)

               
สภาพทั่วไป (GA) :   ซีด (Pale) :   เหลือง (Jaundice) :
ต่อมน้ำเหลือง (Lymh node) :            
ต่อมน้ำเหลืองที่ไหปลาร้าซ้าย (Virchow node) :   ไม่มี (No) : มี (Yes)   ขนาด (Size) :
ก้อนบริเวณ (Mass at) :   ขนาด (Size) : ซม.(cms./FB)      
บริเวณ (At) :   ขนาด (Size) : ซม.(cms./FB)      
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ศีรษะ (Head) :   หัวใจ (Heart) :   ปอด (Lung) :
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Diagnosis.............................................

STAGE...........................