Model essay on Chinese medical record writing
Hospitalization calendar
Name:. Gender: Male Age: 5 years old Nationality:. Place of birth:.
Marital status: unmarried occupation:. Unit:. Postal code: ..
Permanent address: ...
Admission time: April 2002 10, and medical history collection time: April 2002 10.
Medical history statement: reliability of children's mothers: basically reliable onset solar terms: after Tomb-Sweeping Day.
Chief complaint: Repeated fever and cough for 5 days.
Current medical history: Fringe infants began to have fever, cough, excessive phlegm, nasal congestion and vomiting of stomach contents five days ago, with no obvious inducement. I visited our hospital for many times and was treated with traditional Chinese medicine, Xianfeng No.6 and Houttuynia cordata by intravenous drip. The symptoms did not improve. I came to our outpatient clinic again today. For further systematic treatment, I was admitted to the hospital from the outpatient department. Symptoms at admission: mental fatigue, fever, cough, expectoration, shortness of breath, vomiting of stomach contents once, earache, no tinnitus, anorexia, poor sleep, bad stool, three times a day, and urination.
Past medical history: healthy in the past, denying the history of chickenpox, measles, tuberculosis and hepatitis.
Personal medical history: My mother was healthy during pregnancy, gave birth to her first child at full term, and her weight and height at birth were unknown. No history of asphyxia and hypoxia at birth, no pathological jaundice, mixed feeding, regular addition of complementary food, normal growth and development, normal intelligence, timely vaccination.
Allergy history: private prosecution of Qingkailing allergy history, denial of other food and drug allergy history.
Menstrual marriage and childbearing history:
Family history: parents' health. Deny the family history of hereditary diseases.
To physically block an opposing player, as in ice hockey or lacrosse.
T 37℃ P 92 beats/min R 20 beats/min BP
Overall situation:
Looking at God: Conscious, mentally exhausted and with normal expression.
Look at the color: normal face, white color.
Appearance: normal development, average nutrition, thin body.
Posture: Normal posture, natural posture and normal gait.
Voice: The language is clear and moderate, and there is no abnormal sound such as burping, belching, wheezing and moaning.
Smell: no special smell.
Tongue image: red tongue with white fur.
Pulse condition: pulse floating number.
Skin, mucosa and lymph nodes:
Skin mucosa: The skin mucosa has no yellow stain, normal texture and elasticity, slight heat, no sweat, no macula, sores, scars and tumors, no abnormal signs of acupoints, vascular signs, spider nevus and pigmentation. And there are no signs of skin abrasions.
Lymph nodes: Submandibular lymph nodes with peanut size can be palpated, with smooth surface, no tenderness, good mobility and no adhesion.
Head and face:
Skull: Skull is normal, without deformity, tumor and tenderness, hair density, color and distribution are normal, without furuncle, tinea and scar.
Eyes: Eyebrows, eyelashes, eyelids and eyeballs are normal, conjunctiva is slightly congested, sclera is not yellow, cornea is clear, eyes are equicircular, 2.5 mm in diameter, and sensitive to light.
Ear: The auricle is normal without deformity, the external auditory canal is unobstructed, there is no abnormal secretion, the mastoid tenderness, and the hearing is normal.
Nose: No deformity, middle nasal septum, perforation, turbinate hypertrophy or obstruction, abnormal nasal secretions, tenderness of paranasal sinuses and normal sense of smell.
Oral cavity: red lips, no herpes, chapped or ulcer, normal teeth, no bleeding or swelling of gums, no herpes, bleeding or ulcer of oral mucosa, congestion of pharynx (++), swelling of bilateral tonsils II0, middle palate.
Neck:
Shape: symmetrical, no abnormal mass.
Status: no resistance to stiffness and tenderness, no restrictions on activities.
Trachea: centered.
Thyroid gland: no swelling or nodules.
Neck pulse: no abnormal pulsation and murmur, no jugular vein bulging, no hepatocervical reflux sign.
Chest:
Thoracic: symmetrical appearance, no deformity, normal intercostal space, no local uplift, depression, tenderness and percussion pain, no edema, subcutaneous emphysema and mass, no venous dilatation and abnormal reflux.
Breast: normal size, no redness and tenderness.
Lung: Breathing is normal, bilateral breathing activity is normal, voice quiver is normal, both lungs are palpated with clear voice, and the movement of lung and liver voiced boundary, lower lung boundary and lower lung boundary is normal during breathing. Breathing sounds in both lungs are clear, dry and wet rales are not heard in both lungs, and voice conduction is normal. No pleural friction or wheezing.
Heart: The apical beat is located at 0.5cm on the left clavicle midline between the 4th and 5th intercostals. There is no negative apical beat and diffuse beat, no tremor or friction in the precordial area. The left and right voiced boundaries of the heart are shown on the right. The heart beats rhythmically, the heart rate is 92 beats/min, the heart sound is normal, and no pathological murmur is found in the auscultation area of each valve.
Blood vessels:
Arteries: The frequency and rhythm of radial artery are normal, and there is no strange pulse. There is no click between femoral artery and brachial artery.
Peripheral blood vessels: no capillary pulsation sign, no gunshot, no pulse, no abnormal arterial pulsation, Durozzi sign (-).
Abdomen:
Visual diagnosis: symmetrical abdomen, normal size, normal respiratory movement, no swelling, depression, rash, pigmentation, stripes, scars, umbilical hernia, varicose veins, gastrointestinal peristalsis waves.
Palpation: The abdomen is soft without tenderness or rebound pain. Don't refuse to press.
Percussion: drum sound, no active voiced sound, lump.
Auscultation: normal bowel sounds, no breathing, no vascular murmur.
Liver: no tenderness under ribs, no tenderness in liver area.
Gallbladder: untouched, no tenderness in gallbladder area.
Spleen: untouched, no tenderness in spleen area.
Kidney: Both kidneys have no pain in percussion and lumbago.
Bladder: untouched, ureter without tenderness point.
Yin and excreta:
Two yin: the front and back two yin are normal.
Excrement: not checked.
Spinal limb:
Spinal column: Physiological curvature exists, without deformity, rigidity and tenderness, with unrestricted movement, and without tension and tenderness of bilateral muscles.
Limbs: Muscle strength and muscle tension are normal, and there is no trauma, fracture or muscle atrophy. There is no redness, pain, tenderness, edema and dislocation in the joints, normal movement, no deformity, no edema and varicose veins in the lower limbs.
Fingernails: Fingernails are ruddy, shiny and normal in shape.
Nervous system:
Feeling: Pain, temperature, touch, tuning fork vibration and joint position are all normal.
Exercise: no muscle tension and atrophy, no paralysis, no abnormal movements, normal movement and gait.
Superficial reflex: Abdominal wall reflex and plantar reflex are normal, but testicular reflex and anal reflex are not checked.
Deep reflex: Second, triceps reflex, radial membrane reflex, knee tendon reflex and achilles tendon reflex are normal.
Pathological reflex: Hoffman (-), babinski (-), Gordon (-), chaddock (-), Koenig (-).
Laboratory examination: blood analysis: WBC 12.6x 10e9/L, GRAN%76.2%.
Chest X-ray shows: Bronchial infection in both lungs.
Dialectical basis:
Combined with the reference of the four diagnosis methods, this disease belongs to the category of "cough" in traditional Chinese medicine, and the syndrome belongs to "wind-heat type". Infants are young, lung qi deficiency is weak, wind-heat evil attacks, lung collaterals are blocked, and lung qi is lost in Su Xuan, which can cause fever and cough. Nasopharyngeal cavity is the portal of lung and stomach, so you can feel the evil of wind and heat and see the swelling and pain of throat. The lung is closely related to the spleen, and the spleen is also deficient when the lung qi is damaged, so when you see anorexia, stomach loss of balance and falling, vomiting, and abnormal transportation, your stool will be rotten. Red tongue, white fur and floating pulse are all symptoms of exogenous wind-heat
Western medicine diagnosis basis:
1. History: Repeated fever and cough for 5 days.
2. Symptoms and signs: fever, cough, expectoration, vomiting of stomach contents once, earache, anorexia, poor sleep, and rotten stool. Pharyngeal congestion (++), large tonsil II. Breathing sounds in both lungs are thick, and a small amount of dry and wet rales can be heard in both lower lungs.
3. Auxiliary examination: blood analysis: WBC 12.6x 10e9/L, GRAN%76.2%, chest film: bronchogenic infection of both lungs.
Admission diagnosis
Traditional Chinese medicine diagnosis: cough
Wind-heat type
Western medicine diagnosis: acute bronchitis
Intern:
Resident: