Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main concerns related to their incisional hernia. This may include:
Bulge at the incision site
Pain or discomfort at the incision site, especially with exertion
Difficulty lifting or straining
Feeling of something “sticking out”
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms
Size and location of the bulge
Any factors that worsen the bulge or pain (e.g., coughing, lifting)
Prior surgeries (including the one that resulted in the incision)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that may contribute to hernia development (e.g., connective tissue disorders, obesity)
History of smoking (weakens tissues and increases risk)
Prior abdominal surgeries (increases risk of incisional hernia)
家族史 (jiā zú shǐ) Family History:
Family history of hernias (uncommon)
社会史 (shè huì shǐ) Social History:
Current weight and any recent weight changes
Occupational activities that involve heavy lifting or straining
查体 (chá tǐ) Physical Examination:
Vital signs (normal in most cases)
Abdominal examination:
Visible bulge at the incision site
Palpation of the bulge: assess for reducibility (can be pushed back in) and tenderness
Assessment for signs of incarceration (intestinal obstruction) – rare but emergent
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Imaging studies are usually not necessary for diagnosis but may be helpful in complex cases.
Ultrasound (portable or formal):
May be used to visualize the hernia contents and assess for complications.
CT scan (rarely needed):
May be used to evaluate complex hernias or rule out other diagnoses.
诊断 (zhěn duàn) Diagnosis:
Incisional hernia.
Specify the location of the hernia (e.g., ventral, umbilical).
Consider adding descriptors if present (e.g., incarcerated incisional hernia).
分期 (fēn qī) Staging (optional):
Some classification systems categorize incisional hernias based on size.
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment for incisional hernia is typically surgical repair.
Discuss options with the patient, considering factors like hernia size, symptoms, and overall health.
Conservative management (may be considered for small, asymptomatic hernias):
Wearing a supportive binder
Activity modification (avoiding heavy lifting)
Surgical repair: The mainstay of treatment for symptomatic or large hernias.
Several surgical techniques are available, depending on the specific situation.
Discuss the risks and benefits of surgery with the patient.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of the hernia and the chosen treatment plan.
Surgical repair offers the best chance of a complete cure and preventing complications.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following post-operative instructions (pain management, incision care).
Gradual return to activity as tolerated (avoiding heavy lifting).
Maintaining a healthy weight.
Signs and symptoms of complications to watch for (increased pain, nausea, vomiting).
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for follow-up appointments to monitor healing and address any concerns.
Additional Notes:
Document if the patient is a candidate for surgery and their willingness to proceed.
Consider referral to a surgeon specializing in hernia repair for complex cases.