美容皮肤科门诊病历A份
皮肤美容科门诊病历
病历姓名性别联系电话过敏史病案编号病案编号：基本资料姓名性别年龄联系电话单位地址或住址：客户来源：A、转诊 B、VIP共享 C、电话咨询D、网络咨询E、门诊F其他基本情况：过敏史治疗史高血压（是） (否) 心脏病（是） (否)糖尿病（是） (否) 癫痫病（是） (否)疤痕体质（是） (否)近期用药史其它专科情况临床诊断激光治疗协议书一、治疗前需照像作为病例资料保存。
二、如身体处于特殊时期（孕期、哺乳期等）暂不能行激光治疗，如有上述情况，治疗前应向医生说明。
三、部分治疗术前采用表面麻醉药膏进行表麻，个别病人对麻醉药膏有过敏反应，此现象属个体差异，需改用其它方法麻醉。
四、患有精神异常、全身重要器官疾病者不宜手术，术前应告知医生，若隐瞒病史，一切后果自负。
五、瘢痕体质者术后有瘢痕增生可能。
、六、色素痣存在一定的恶变几率，术前无法预知，如近期有增大、变色、瘙痒、疼痛、出血及原有毛发脱落等异常情况，应在治疗前向医生讲明，必要时作病理检查。
七、术后应严格遵医嘱，如护理不当，会出现感染、伤口愈合延迟、色素沉着或瘢痕形成可能。
八、由于个体差异较大，每一种组织细胞对激光的敏感性不同，治疗效果及显效速度也存在个体差异。
九、由于每个人对光的敏感性存在差异，治疗后部分患者会出现紫癜或水泡、色素沉着或色素脱失，经过适当处理，紫癜或水泡一般会在24-96小时后逐渐消失，色素沉着或色素脱失，一般在1-6个月内可逐渐消退，极少数个体可能出现永久色素沉着或色素脱失。
十、姓名、通讯地址及电话必须真实有效，否则因此而延误治疗、护理所造成的后果由患者自负。
激光术后注意事项1、暴晒前一个月，暴晒后一个月暂不做治疗，请注意避开该时间段；术后当天清洗治疗区域避免水温过热/治疗区域保持干燥，不能沾水；两天内禁焗桑拿，泡温泉。
2、激光、彩光嫩肤治疗后，部分患者可能会出现皮肤轻微泛红，紧绷感，少数会出现水泡，结痂等均为正常现象。
3、治疗后一周内治疗区域不能使用含果酸、A酸、磨砂类护肤品，禁用阿司匹林类药物和酒精（包括含有酒精的化妆品），切不可挤、压、碰、磨擦治疗面。
皮肤科病历-文书模板
皮肤科病历-文书模板一、基本信息姓名：[患者姓名]性别：[患者性别]年龄：[具体年龄]民族：[民族]婚姻状况：[已婚/未婚/离异等]职业：[职业]联系电话：[电话号码]住址：[详细住址]就诊日期：[具体年月日]二、主诉[简洁描述皮肤问题及持续时间，如“皮肤瘙痒1 周”“皮疹3 天”等。
]三、现病史1. 起病情况：详细描述症状出现的时间、诱因等。
例如：“1周前无明显诱因出现皮肤瘙痒，起初为局部瘙痒，逐渐扩散至全身。
”2. 主要症状特点：瘙痒：程度（轻度、中度、重度）、性质（持续性、间歇性、阵发性等）、是否伴有疼痛、灼热感等。
“瘙痒为中度，呈持续性，无疼痛和灼热感。
”皮疹：形态（红斑、丘疹、水疱、风团等）、颜色、大小、分布部位、是否对称等。
“全身散在红色丘疹，直径约23 毫米，部分融合成片，主要分布在四肢和躯干，对称分布。
”脱屑：有无脱屑，脱屑的程度、颜色等。
“部分皮疹表面有少量白色鳞屑。
”渗出：是否有渗出液，渗出液的性质（浆液性、脓性等）、量的多少等。
“无渗出液。
”3. 病情发展与演变：描述症状的变化情况，是否加重、减轻或出现新症状。
如：“近几天瘙痒加重，皮疹增多，部分丘疹变为水疱。
”4. 伴随症状：是否有发热、关节疼痛、乏力等伴随症状。
例如：“无发热、关节疼痛、乏力等症状。
”5. 诊疗经过：患者就诊前的检查、治疗情况。
如：“自行涂抹皮炎平软膏，症状无明显缓解。
曾在社区诊所就诊，给予抗过敏药物（具体名称）口服，瘙痒稍有减轻，但皮疹未消退。
”四、既往史1. 一般健康状况：良好/一般/较差。
2. 皮肤疾病史：有无湿疹、荨麻疹、银屑病等皮肤病史；有无过敏史。
例如：“既往有荨麻疹病史，对海鲜过敏。
无其他皮肤病史。
”3. 全身疾病史：有无高血压、糖尿病、心脏病等慢性疾病史；有无肝炎、结核等传染病史；有无手术史、外伤史、输血史等。
“既往体健，无慢性疾病史，无传染病史，无手术史、外伤史、输血史。
”4. 药物过敏史：对哪些药物过敏。
皮肤科病历范文30份
皮肤科病历范文30份英文回答：I have treated numerous patients in my dermatology practice and have encountered a wide range of skin conditions. Here are 30 sample cases from my experience:1. Patient presented with a red, itchy rash on their arms and legs. After examination, I diagnosed them with eczema and prescribed a topical corticosteroid cream to reduce inflammation and itching.2. A middle-aged woman came in with a cluster of small, fluid-filled blisters on her lips. This was a classic case of herpes labialis, commonly known as cold sores. I prescribed antiviral medication to shorten the duration and provided advice on preventing future outbreaks.3. A teenage boy complained of persistent acne breakouts. I recommended a combination of topicaltreatments, such as benzoyl peroxide and retinoids, along with oral antibiotics to control the bacterial infection.4. An elderly man presented with a large, irregularly shaped mole on his back. I performed a biopsy and determined it to be a melanoma, the most aggressive form of skin cancer. The patient underwent surgical excision and regular follow-up visits to monitor for recurrence.5. A young woman came in with hair loss and thinning. After evaluating her medical history and conducting blood tests, I diagnosed her with female pattern hair loss. I discussed treatment options, including minoxidil and hair transplantation.6. A child had a persistent, itchy rash on the folds of their skin. This was diagnosed as atopic dermatitis, also known as eczema. I prescribed a moisturizing cream and advised the parents on managing triggers, such as certain foods and environmental factors.7. A middle-aged man had a red, scaly rash on his scalpand eyebrows. This was indicative of seborrheic dermatitis, a common condition that causes dandruff. I recommended using a medicated shampoo containing ketoconazole or selenium sulfide.8. A woman in her 30s had dark patches on her face. This was diagnosed as melasma, a common skin condition triggered by hormonal changes. I prescribed a combination of topical creams containing hydroquinone and advised her on sun protection measures.9. A man complained of intense itching and a rash in his groin area. This was diagnosed as a fungal infection, commonly known as jock itch. I prescribed an antifungal cream and advised him on maintaining proper hygiene and wearing breathable clothing.10. A teenager had thick, scaly plaques on their knees and elbows. This was diagnosed as psoriasis, a chronic autoimmune condition. I prescribed topical corticosteroids and discussed lifestyle modifications, such as stress management and avoiding triggers.11. A young girl had small, itchy bumps on her arms and legs. After examination, I diagnosed her with keratosis pilaris, a common harmless condition. I recommended moisturizing creams and gentle exfoliation to improve the appearance of the bumps.12. An adult had a painful, red lump on their back. This was diagnosed as a furuncle, commonly known as a boil.I recommended warm compresses and prescribed antibiotics to treat the infection.13. A woman presented with thinning and brittle nails. After ruling out underlying medical conditions, I diagnosed her with onychoschizia, a condition characterized by splitting and peeling nails. I advised her on proper nail care and recommended biotin supplements.14. A man had a persistent, itchy rash in the folds of his skin. This was diagnosed as intertrigo, a common condition caused by friction and moisture. I recommended keeping the area clean and dry, along with using a barriercream.15. A child had red, scaly patches on their scalp. This was diagnosed as scalp psoriasis. I prescribed a medicated shampoo containing coal tar or salicylic acid and advised the parents on gentle scalp care.中文回答：我在皮肤科的实践中治疗了许多患者，遇到了各种各样的皮肤问题。
整形外科门诊病历
整形外科门诊病历病程记录单告知书尊敬的顾客及家属：依照国务院令第351号的规定：“在医疗机构及其医务人员应当将患者的病情、医疗措施、医疗风险等如实告知患者，及时解答其咨询。
但是，应当避免对患者不利后果”；卫生部《病历书写基本规范》第十条规定：“对需取得患者书面同意方可进行的医疗活动，应当由患者本人签署知情同意书。
患者不具备完全民事行为能力时，应当由其法定代理人签字；患者因病无法签字时，应当由其授权的人员签字；为抢救患者，在法定代理人或被授权人无法及时签字的情况下，可由医疗机构负责人或者授权的负责人签字。
因实施保护性医疗措施不宜向患者说明情况的，应当将有关情况告知患者近亲属，由患者近亲属签署知情同意书，并及时记录。
患音无近亲属的或者恩者近亲属无法意书的，由患者的法定代理人或者关系人签署同意书”为切实履行患者的知情同意权和实施保护性医疗措施，敬请你们根据自己的实际情况，慎重考虑，选择确定作为患者病情，医疗措施、医疗风险等的被告知者，并签署各项医疗活动同意书。
…………………………………………………………………………………………知情选择书上述告知书内容本人己充分了解，经慎重考虑，我选择本人作为在该院医疗期间的病情、医疗措施、医疗风险等的被告知者，并签署各项医疗活动同意书。
患者签名: 日期：年月日上述告知书内容本人己充分了解，为有利于本人的疾病诊疗和康复，我选择以授权方式行使本人在医疗期间的知情同意权和选择权。
监护人或亲属签名：日期：年月日一般检验报告粘纸粘贴：血液□大便□小便□生化检验及未规定贴入特殊检查贴纸的报告姓名：病室：床号：门诊号：住院号：注意事项1. 报告单依次贴在粘贴线上。
2. 粘贴必须整齐、清洁。
皮肤科大病历书写范文
皮肤科大病历书写范文英文回答：As a dermatologist, I come across a variety of skin conditions in my practice. One common condition that Ioften see is eczema. Eczema is a chronic inflammatory skin disorder that can cause itching, redness, and dryness. It can be quite uncomfortable for the patients and can affect their quality of life.When a patient with eczema comes to see me, I start by taking a detailed medical history. I ask about their symptoms, such as when they first noticed the rash, if itis itchy, and if they have any triggers that worsen the condition. I also inquire about their personal and family history of eczema or other allergic conditions.After taking the medical history, I conduct a thorough physical examination of the patient's skin. I look for any signs of inflammation, such as redness, swelling, or oozing.I also inspect the affected areas for any secondary infections that may have developed due to scratching.In some cases, I may need to perform additional tests to confirm the diagnosis or rule out other skin conditions. These tests may include a skin biopsy or patch testing to identify specific allergens that may be triggering the eczema.Once the diagnosis is confirmed, I discuss the treatment options with the patient. I explain that eczemais a chronic condition that cannot be cured, but it can be managed effectively. I recommend a combination of lifestyle modifications and medications to control the symptoms.Lifestyle modifications may include avoiding triggers such as certain fabrics or detergents that irritate the skin. I also advise patients to keep their skin moisturized and to avoid excessive bathing or hot water, as it can dry out the skin further.In terms of medications, I may prescribe topicalcorticosteroids to reduce inflammation and itching. In severe cases, I may prescribe oral corticosteroids forshort-term use. Other options include topical calcineurin inhibitors, antihistamines, and immunomodulators.Regular follow-up visits are essential to monitor the patient's progress and adjust the treatment plan if necessary. I encourage my patients to ask questions and express any concerns they may have during these visits. Itis important to have open and honest communication toensure the best possible outcome.中文回答：作为一名皮肤科医生，我在我的实践中经常遇到各种皮肤疾病。
美容皮肤科门诊病历书写范文
美容皮肤科门诊病历书写范文英文回答：As a dermatologist, I often encounter patients with various skin concerns in my cosmetic dermatology clinic. It is essential to maintain accurate and detailed medical records to provide the best possible care for my patients. Here is an example of how I would write a medical recordfor a patient with a common skin condition.Patient Information:Name: John Smith.Age: 35。
Gender: Male.Date of Visit: 1st October 2021。
Chief Complaint:The patient presented with a complaint of persistent acne on his face.History of Present Illness:The patient reports that he has been experiencing acne breakouts for the past six months. He mentions that the acne primarily affects his forehead, cheeks, and chin. The patient has tried over-the-counter acne treatments without significant improvement. He is concerned about the appearance of his skin and the negative impact it has on his self-esteem.Past Medical History:The patient has no significant past medical history. He has never experienced any skin conditions before.Review of Systems:The patient denies any other symptoms or complaints. There is no history of allergies or sensitivities to medications.Physical Examination:Upon examination, the patient has multiple comedones, papules, and pustules on his forehead, cheeks, and chin. The lesions are predominantly inflammatory with some evidence of scarring. The rest of the physical examination is unremarkable.Assessment and Plan:Based on the patient's history and physical examination findings, the diagnosis of moderate acne vulgaris is made.I explained to the patient that acne is a common skin condition caused by a combination of factors such as excess oil production, clogged pores, bacteria, and inflammation.I discussed the treatment options with the patient, including topical retinoids, benzoyl peroxide, and oral antibiotics. I also emphasized the importance of a properskincare routine and lifestyle modifications, such as avoiding excessive sun exposure and maintaining a healthy diet.I prescribed a topical retinoid cream to be applied once daily in the evening, along with a benzoyl peroxide wash to be used twice daily. I also prescribed an oral antibiotic to be taken daily for six weeks to help reduce the inflammation and control the acne. I informed the patient about possible side effects and advised him to follow up in four weeks to assess the treatment's effectiveness and make any necessary adjustments.中文回答：作为一名皮肤科医生，在我的美容皮肤科门诊中，我经常遇到各种皮肤问题的患者。
皮肤科病历模板
皮肤科病历模板
以下是一份基本的皮肤科病历模板，仅供参考：
患者姓名：_____________________
性别：_____________________
年龄：_____________________
主诉：__________________________
现病史：
1.病程：起病时间、病情进展情况等。
2.症状：主要症状、症状持续时间、症状程度等。
3.治疗史：曾经接受过哪些治疗、治疗效果如何等。
4.其他病史：有无其他疾病史、过敏史、家族史等。
既往史：
1.过敏史：曾经对哪些物质过敏、过敏反应的程度等。
2.家族史：家族中有无遗传性疾病史、皮肤病史等。
体格检查：
1.皮肤检查：检查皮肤的颜色、质地、温度等。
2.淋巴结检查：检查颈部、腋窝、腹股沟等部位的淋巴结是否肿大。
3.其他检查：根据病情需要进行相应的检查。
诊断：
1.根据病史、体格检查和实验室检查结果，确定诊断。
2.根据病情需要进行进一步检查和治疗。
治疗方案：
1.根据诊断结果，制定个性化的治疗方案。
2.治疗方案包括药物治疗、物理治疗、手术治疗等。
随访计划：
1.根据病情需要，制定随访计划。
2.随访计划包括定期复诊、药物治疗、物理治疗等。
注意事项：
1.请按时复诊，并按照医生的建议进行治疗。
2.治疗期间注意休息，避免过度劳累。
3.饮食要清淡，避免食用刺激性食物。
4.如有不适症状，请及时就诊。
北京医疗美容专用病历模板
病案号（ID）：北京邦定美容整形外科门诊部门诊病历（式样）患者姓名(Name)：性别(Gender)：年龄(Age)：住址(Address)：药物过敏史(Drug allergy history)：北京市医疗美容、整形外科专科机构门诊病历首页门诊病案号：姓名性别出生年月日婚姻状况职业出生地省（市）县国籍民族身份证号通信地址：邮编联系电话联系人姓名联系人电话首诊科别首诊日期：年月日时首诊医师复诊科别复诊日期：年月日时复诊医师复诊科别复诊日期：年月日时复诊医师复诊科别复诊日期：年月日时复诊医师附件3：病历记录病历记录就诊时间：年月日时病案号：主诉：现病史：既往史：外伤史□ 1、有 2、无手术史□ 1、有 2、无高血压病史：□ 1、有 2、无心脏病史：□ 1、有 2、无糖尿病史：□ 1、有 2、无药物过敏史：□ 1、有 2、无(注明药物名称)既往与本次就诊相关疾病的治疗史：□ 1、有 2、无查体：体温：℃，脉搏：次/分，呼吸：次/分，血压： mmHg。
一般情况：（发育、营养等）：双肺呼吸音□ 1、正常 2、异常：心脏：心率次/分心律：□ 1、正常 2、异常病理性杂音：□ 1、无 2、有腹部：□ 1、软，无压痛 2、有压痛肝：□ 1、正常 2、异常脾：□ 1、正常 2、异常专科情况：辅助检查结果：血常规：快速免疫检查：初步诊断：治疗建议：医师签名：附件4：病历续页病案续页姓名： 病案号: 年 月 日 时 科别：附件5 ：门诊手术记录门诊手术记录姓名性别年龄病案号手术日期：年月日手术时间小时分术前诊断：术后诊断手术名称：手术医师：术者一助二助器械护士巡回护士麻醉方式麻醉医师术中出血量ml 手术过程:术后医嘱：医师签字：附件6 ：门诊非手术治疗记录非手术治疗记录姓名性别年龄病案号治疗日期：年月日治疗时间：小时分治疗前诊断：治疗内容与方法：治疗医师：一助：二助：护士：麻醉方式：麻醉医师：治疗过程:医嘱：医师签字：附件7：护理记录单护理记录单病情记录日期时间护士签字附件8：体温记录姓名26102610261026102610261026102610261026102610261026102610华氏脉搏体温10710610510410310299989695942034上午下午上午下午上午下午上午下午上午下午上午下午 周输入液量尿 量血 压体 重4035呼 吸大便次数8037976036101100381001404012039上午下午16041日 期患病日数手术日数时 间体温记录男年龄 入院日期科室病案号附件9：患者就诊告知患者就诊告知一、患者就诊时须使用真实姓名，如实填写工作单位、家庭住址、身份证号码、联系人、联系电话等各项内容。
医疗美容门诊病历
—————————————————————————————陕西华一生物科技有限公司曲江新区医疗美容诊所—————————————————————————————医疗美容门诊病历姓名：___________________性别：______ 年龄：______门诊号：_________________过敏史：_________________—————————————————————————————医疗美容门诊病历门诊号：门诊手术记录门诊号：检查报告粘贴单——————————————————————————————————————————————————————————手术知情同意书附录：（一）重睑术1.术后眼睑肿胀1-2周，有轻微紧缩感或乏力感。
2、术后重睑形态两侧因肿胀程度不同有可能不对称，但恢复后直视下一般不易被察觉。
3、早期切口有瘢痕增生、发红、发硬、发痒等现象出现的可能。
完全恢复自然约需2-6个月，达到自然状态的时间因个体差异而不同。
（二）眼袋整形术1.术后可能有切口痕迹或瘢痕轻微增生的现象，一般在3-6个月后逐渐减轻至不明显。
2.本手术对外眼角及睑缘下皱纹只能起减轻作用。
3.术后早期因肿胀有引起下睑轻度外翻的可能性，2-3个月后可逐渐恢复。
（三）上睑下垂矫正术1.手术目的只能尽可能地使双眼平视时达到对称状态，使角膜显示率增加，眼睛神态感增强。
2、术后形态不可能像重睑那样自然。
若为单侧，术后患侧与对侧形态不能达到绝对一致。
3、术后可能有睑闭合不全现象存在。
（四）隆鼻术1.切口在短期内（2周至2月）有发红现象的可能，恢复后一般不会被看出。
2、有排异反应的可能性，如发生，需取出假体。
3、术后假体在面部中线左右可能会有5°内的偏科，但恢复后直视下一般不易被察觉。
（五）瘢痕切除术1.瘢痕不可能完全祛除，只有达到大瘢痕变小瘢痕的目的，切除缝缩后仍会有轻微痕迹，2、在瘢痕增生期（2周至6月内）切口有发红发硬、发痒等现象的可能性。
美容病历
大连李达美容外科诊所医疗整形美容病志病案号：姓名：性别：出生年月日周岁民族婚姻职业住址：联系电话：手机：固话：单位：主诉：病史1.现病史2.既往病史①有无高血压、糖尿病、冠心病史（）②有无肝炎、结核病等传染病史（）③有无手术外伤史（）④是否住过院，为什么住院3.药物过敏史（）若有为青霉素（）麻药（）其他（）4.有无家庭遗传病史（）是否在月经期（）生育情况（）5.个人史：体格检查：1.体温脉搏呼吸血压皮肤粘膜淋巴结头部及其器官颈部胸部腹部直肠肛门外生殖器脊柱四肢神经系统2.专科情况：3.辅助检查：初步诊断：治疗方案：记录时间：医生签字：大连李达美容外科诊所手术记录患者姓名：性别：年龄：手术时间：手术医生：助手：护士：实施麻醉：麻醉师：假体类型：实施手术：术中经过及处置：绘图：术后医嘱：医生签字：记录时间：复诊记录大连李达美容外科诊所医疗整形美容手术协议书姓名：性别：年龄：手术日期：手术名称：假体类型：术者：助手：护士：拟施麻醉：麻醉师：术前情况：术前须知：1、美容医生虽然尽了最大努力，但是由于个人审美观念和现代医疗水平有限，不一定都能满足各自的需要，可能出现效果不理想及相应并发症。
若出现以上情况，可在本院治疗，手术费、医疗费一律不退。
2、患者术后应严格遵医嘱（含口头医嘱）治疗，若出现异常，应及时来本院就诊，医生尽快诊治，患者应予以配合。
3、患者有精神异常史或瘢痕体质等其他疾病不宜手术，术前应告诉医生，若隐瞒病史，由此出现异常，由患者本人及家属负责。
4、患者术后因手术部位肿胀，恢复期（三个月到半年）也可能产生不对称，因患者年龄、体质、手术部位不同而有所差异，患者应予以理解。
5、患者在整形手术前、后必须照相，相片为医院病历资料，本院有权选作学术交流资料。
6、某些整形手术需采用软组织代用品（国家标准号），可能出现个别人排异反应，医生与患者都难以预测，如若发生，可表现为局部红肿，渗透乃至破溃，系患者个人体质所致，与手术本身无关，患者应予以理解并及时就医，医生尽快诊治，患者不能因此无理纠缠。
中医皮肤科病历范文
中医皮肤科病历范文英文回答：I went to see a traditional Chinese medicine dermatologist for my skin condition. The doctor carefully examined my skin and asked me about my symptoms and medical history. After the examination, the doctor explained to me that according to Chinese medicine principles, my skin condition is caused by an imbalance of Qi and blood circulation in my body.The doctor prescribed a herbal medicine formula for me to take orally. The formula contains various herbs that are believed to nourish the blood and promote Qi circulation. I was instructed to take the herbal medicine twice a day for two weeks. Additionally, the doctor recommended somedietary changes to support the treatment. I was advised to avoid spicy and greasy foods, and to include more fruits and vegetables in my diet.In addition to the herbal medicine, the doctor also performed acupuncture on me. Acupuncture is a technique where thin needles are inserted into specific points on the body to stimulate Qi flow. The doctor explained that acupuncture can help regulate the flow of Qi and blood, and promote healing of the skin. The acupuncture treatment was painless and I felt relaxed during the session.After two weeks of following the treatment plan, I noticed significant improvement in my skin condition. The redness and inflammation had reduced, and the itching had subsided. I continued with the herbal medicine and acupuncture for another two weeks, and my skin continued to improve.Overall, I am very satisfied with the treatment I received from the traditional Chinese medicine dermatologist. The combination of herbal medicine and acupuncture proved to be effective in treating my skin condition. I appreciate the holistic approach of Chinese medicine, which focuses on addressing the root cause of the problem rather than just treating the symptoms.中文回答：我去看了一位中医皮肤科医生，为了治疗我的皮肤问题。
医疗整形美容门诊病例模板
重睑术主诉：单眼皮,影响美观5年余现病史：患者于5年前无明显诱因发现双侧上睑是“单眼皮”，且上睑较肿，晨起及哭泣时明显,随年龄增长，“单眼皮"及上睑臃肿的形态无明显改善，一直未予诊治，现觉上睑形态影响美观，遂来我院要求手术治疗。
既往史：体健，否认外伤及手术史,否认药物、食物过敏史,否认心脑血管等重大疾病史.专科情况：头颅五官无畸形，双侧瞳孔等大、等圆，上、下睑眼睑无外翻，上睑较臃肿，按压双上睑可触及眶内脂肪较多。
上睑遮盖角膜上缘约2mm，下睑缘与角膜边缘相接触。
双侧上睑形态不对称,睁闭眼时可见左侧重睑皱褶，较窄，右侧未见重睑皱褶.（内眦部见蹼状皮肤皱褶，斜行遮盖内眦角和泪阜。
-内眦赘皮）双侧上睑提肌力约为10mm，双眼角膜及结膜未见炎症反应。
辅助检查：血常规:正常;HBsAg：阴性。
初步诊断：1.双侧单睑 2.处理：1，拟于今日在局麻下行“重睑术”。
2，术后抗炎、消肿等治疗。
医师签名：手术记录1：重睑+内眦切开患者取平卧位，常规消毒铺巾。
术前于双上睑及内眦部设计并标画拟重睑线。
行双侧内眦设计L型手术切口，局部麻醉后，切开皮肤,局部剥离，显露内眦韧带，达到内眦显露效果，用8—0丝线缝合切口。
行双侧上睑局部注射局麻药后,沿术前设计的重睑线切开上睑皮肤，分离并切除部分重睑线以下的眼轮匝肌，暴露睑板前组织及提上睑肌腱膜，打开眶隔，祛除自然疝出的脂肪,电凝止血。
用7—0尼龙线，将切口上下创缘与睑板前筋膜间断缝合固定，双侧同时缝合，并对比。
术程顺利,术中麻醉效果良好,出血量少。
术毕，安返。
手术记录2：重睑埋线+内眦横行切口患者取平卧位，常规消毒铺巾。
术前于双上睑及内眦部设计并标画拟重睑线.行双侧内眦设计L形手术切口，局部麻醉后，切开皮肤，局部剥离，显露内眦韧带，达到内眦显露效果，祛除多余皮肤，用7-0丝线缝合皮肤。
行双侧重睑术。
行右侧手术。
在重睑线上做两个长约2mm的皮肤切口a、b，用7-0的尼龙线于皮肤切口a点进针,翻转上睑，由结膜面出针c点，再由c点进针经粘膜下至d 点出针,相当于b点皮肤切口处，由d点进针翻转上睑至b点出针，由b点进针经皮下至a点出针。
医疗美容门诊病历
病案号轻医美医疗美容门诊病历姓名______________________________性别______________________________出生年月_____________________________居住地址_____________________________联系电话_____________________________初诊日期_____________________________美容微创科门诊病历（首页）姓名：性别：年龄：病案号：住址：电话：婚姻状况：职业：主诉：________________________________________________________________________________ 现病史：______________________________________________________________________________近期服用的药物：□降压药□阿司匹林口避孕药口安眠药□糖皮质激素□氨基糖昔类抗生素□其他既往史：口遗传病□光敏史□过敏史□瘢痕体质□凝血机制异常□精神病史□糖尿病□高血压□手术口麻醉□其他_____________________ 末次月经：__________ 曾经注射：____________________专科检查：口下面部咬肌肥厚、触之硬，咬合时隆起。
□面部轮廓欠佳，下颌缘欠流畅。
□双侧外眦部放射状皱纹，下睑细纹，活动时加重。
伴静态皱纹；□无□有□额部皱纹，抬额加重。
伴静态皱纹；□无□有口眉间皱纹，皱眉时加重。
伴静态皱纹；口无□有口鼻背部皱纹，皱眉时加重。
伴静态皱纹；□无□有口颤区凹陷□额区凹陷口面颊凹陷□内眦眶下缘沟壑口颤弓下凹陷口鼻唇沟纹口鼻部低平口口唇欠饱满，形态欠佳□下须较短，形态欠佳口面部皮肤松垂口双小腿粗壮，可见腓肠肌隆起，触之硬。
口双侧肩部宽厚，可见斜方肌紧张，触之硬。