西安交通大学第二附属医院

                        门诊病历记录

就诊费别：自费                                           登记号：0000573219

                                                                    
姓名：               性别：男          年龄：22岁

科室：精神心理科门诊                   就诊区域：综合楼2楼C区

初诊日期：2017—07—26 15：33：15     接诊医生：王心辛

复诊日期：                             复诊医生：

                                                                                  
主诉：精神分裂症病史5年。
现病史：精神分裂症病史5年，疑心大，2年前曾于精神卫生中心住院治疗，目前服药“喹硫平”150mg一次/日、“齐拉西酮”60mg一次/日、“苯海索片”2mg一次/日，症状较前改善。今日行EEG大致正常，咳嗽1月余，睡眠时早醒。
既往史：
过敏史：
家族史：
查体：意识清，精神可，接触尚可，检查能配合，问答基本切题，思维稍迟钝，

情绪较平静，意志行为活动可，自知力存在。

治疗意见：继续药物治疗！呼吸科会诊！

诊断：偏执型精神分裂症

医嘱：

        脑地形图×1—|—脑电图×1

        右佐匹克隆片*1盒 1mg 每日1次 口服

                                                                                    医师签名：王心辛

                                                                           The Second Affiliated Hospital of Xi’an Jiaotong University

                                                                                                Medical record at Outpatient Clinic

Payment type: At one’s own expense                                        Registration number: 0000573219

Name:                        Gender: Male                          Age: 22  

Department: Psychiatricclinic      Outpatient area: Area C, #2 Complex Building

Date of the first visit:15:35:15, July 26^th, 2017   Physician: Wang Xinxin  

Date of the return visit:    Physician of the return visit:

Main complaint: The patient had a history of schizophrenia for 5 years.

History of presentillness: The patient had a history of schizophrenia for 5 years and was strongly dubious and suspicious. He was hospitalized to the Mental Health Center of Xi'an City two years ago. Currently he took 150mg Quetiapine FunarateTablets, 60mg Ziprasidone Hydrochloride Tablets, and 2mg Benzhexol Hydrochloride Tablets, once daily. The symptoms were improved than before, and EEG performed today showed normal results. The patient had cough for about 1month, and tended to wake up early in the morning.

History of pastillness:

History of allergy:

Family history:

Physical examination: The patient had clear consciousness, moderately good spirit andmoderate communication. He could cooperate with physical examination and provide appropriate answers to questions. He was slightly slow in thoughts, but emotionally calm. His volition, behavior and mobility were moderately good. The insight was present.

Therapy advice:Continue medication and consultation at respiratory department.

Diagnosis:Paranoid schizophrenia

Medicalinstruction: Brain mapping×1, EEG×1

One box of Dexzopiclone Tablets,1mg, once daily.

                                                                                                                        Physician signature: Wang Xinxin