เลขที่บัตรผู้ป่วย :
ชื่อ - สกุล (Name - Surname) :
อายุ (Age) :
การวินิจฉัยโรค ระดับผู้ป่วย
การตรวจร่างกาย (PE)
สภาพทั่วไป (GA) :
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ซีด (Pale) :
เหลือง (Jaundice) :
ต่อมน้ำเหลือง (Lymh node) :
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ต่อมน้ำเหลืองที่ไหปลาร้าซ้าย (Virchow node) :
ไม่มี (No) :
มี (Yes)
ขนาด (Size) :
ซม.(cms.)
ก้อนบริเวณ (Mass at) :
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ขนาด (Size) :
ซม.(cms./FB)
บริเวณ (At) :
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ขนาด (Size) :
ซม.(cms./FB)
บวมบริเวณ (Edema) :
ศีรษะ (Head) :
Fobertjex
หัวใจ (Heart) :
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ปอด (Lung) :
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ช่องท้อง (Abdomen) :
สภาพจิต (Mental status) :
Diagnosis.............................................
STAGE...........................