[这个贴子最后由loner163在 2002/03/03 10:34am 编辑]
×××××医院病理解剖记录单 剖验号________
姓名 籍贯
性别 住址
年龄 死亡时间 年月日时分
婚姻 解剖时间
民族 送检医院
职业 剖验者
临床病史摘要：________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
身长_______cm体重_______kg发育_____营养________尸僵________尸斑_______
皮肤:色泽_____弹性_____水肿_____-出血斑点________皮疹_______皮温_______
淋巴结(耳前,耳后,枕后,颈后,颈前,颌下,颏下,锁骨上,膕窝,滑车):___________
头颅(大小,畸形,包块,凹陷)______
眼:结膜_______巩膜______角膜________瞳孔_______左___cm右___cm其他______
耳:耳廓(瘘管)_____外耳道分泌物_________
鼻:分泌物_________外形____________
口:唇(色,疱疹,龟裂)______粘膜___舌(苔)_______腮腺导管分泌物_____
牙列(缺,龋,义齿)________牙龈(肿胀,溢脓,出血,色素沉着)_________
咽(扁桃体,悬雍垂)____________其他_________
颈(甲状腺,淋巴结)__________________________
外生殖器及肛门(注意强奸,鸡奸)_____________________
四肢________________________________________________
胸腔
表面观(瘢痕,乳房,胸廓(桶状,扁平,鸡,漏斗胸))_______________
二肺情况(收缩,粘连)_____________________________
大小:左__cm右___cm重量:左___克 右___克
左肺:表面____________切面____________________实变情况______________支气管_______
粘液____________血管_________________淋巴结_______________________
右肺
同上)_________________________________________________________________
胸腔积液:左___________ml性质______________________
右___________ml性质______________________
心:心包积液(<30ml)___________ml性质________________(心包)粘连___________
心脏重量___________kg心外膜_________卵圆孔__________室间隔___________
心内膜____________心肌(厚薄,色泽,坏死,瘢痕,梗塞)______________
心房:左_________右________心室:左_______右_________
三尖瓣:周径________cm瓣膜情况____________腱索(粗细,粘连)(注意相连在心瓣的边
际和心瓣的心室面)____________________________
二尖瓣(同上)______________________________________________
肺动脉瓣_____________________________________________
主动脉瓣___________________________________________
血管(管壁大小,壁厚薄,内膜,粥样斑块,溃疡,血栓阻塞,压迫)
主动脉_____________肺动脉__________________肺静脉______________
上腔静脉_______________下腔静脉_________________胸导管___________
冠状动脉_____________________________________________________
胸腺(萎缩)_______________________
气管_______________________
食管______________
膈(左右第__肋间)__________________
腹腔一般情况:皮下脂肪厚度____cm颜色_____腹膜(粘连)_____________腹腔积液____cm
性质________________各脏器位置和其他(粘连,肠系膜淋巴结)_________
脾:___kg大小____cm包膜___________________切面_________________________________
胃:内容_________量________ml性质____________粘膜____________________溃疡______
位置_________________
十二指肠:粘膜_______________壶腹部_______________溃疡__________位置__________
胆道:重胆管______________胆石______胆囊_________粘膜_________胆汁_________
胰:_______kg大小_______cm切面________
肝:肝下縁(肋下___cm剑突下_____cm)______kg_______cm表面(包膜厚薄,色泽)__________
切面(小叶,肝内导管)______________门脉系统______________________________
肾上腺:左___克______cm右________克________cm切面_______________________
肾:左肾:_______kg________cm包膜________表面____________切面_____________皮质厚度
______cm肾盂________粘膜________结石_________输尿管________________
右肾(同上)__________________________________________________________________
膀胱:积尿量_______ml性质__________粘膜________________肌小梁_______________
输尿管口____________
男性生殖系:前列腺______睾丸______精囊_____附睾_______阴茎________
女性生殖系:外阴_________阴道___________宫颈阴道部_____宫体_______cm内膜_______
宫肌________外膜_________输卵管_________卵巢左__cm右____cm
囊肿性质______直径______cm黄体___________白体_______________
小肠:浆膜________内容无性质______________粘膜_____________
大肠:浆膜________内容物性质______________粘膜_____________痔___________
腹腔大血管___________________________________________________________
脑:外观____________重量___________kg
硬脑膜______________________________软脑膜_______________________________
脑脊液______________________________脑下垂体______________________________
切面______________________________________________________________________
颅腔:血窦____________中耳__________________蝶骨窦_______________________
脊椎______________________脊髓(取于何处,性质)________________________________
其他____________________________________________________________________________
各脏器镜下观:
(大量盗版上海某医大教研室的材料,非我版权,希望对大家有好处)
