Write a composition in medical record format
Should fill in the year, month and day of illness statement: fill in "patient"; If it is described by others, explain the reliability. 2) Chief Complaint ● There are two space bars between the main content of the electronic medical record and the chief complaint.
The following subheadings, such as "current medical history", require the same distance from the main text. ● The main symptoms, location and duration of the patient's admission (if the time is short, such as acute abdomen, the number of hours should be indicated), such as "continuous fever for 6 days, red maculopapules all over the body for 3 days".
● It is not recommended to replace symptoms with diagnosis or test results. ● If there is more than one chief complaint, it should be listed separately in the order of occurrence, such as "intermittent empty abdominal pain 1 year, tarry black stool 1 day"; Frequent urination and urgency for 3 hours.
3) Current medical history ● According to the time sequence of symptoms, accurately record the onset date, onset priority, onset inducement, occurrence time of each important symptom and its development and change process. Negative symptoms related to differential diagnosis should also be recorded (with symptomatology and differential diagnosis as the main contents).
When describing symptoms, we should grasp the key points and be systematic. For example, when describing pain, we should make clear the location, time, nature, degree and other related factors of pain, as well as the influence of treatment. ● Ask the accompanying symptoms according to the system to avoid omission.
● Previous examination and treatment. ● If the details of the accident, suicide or murder are related to the illness, they should be recorded objectively and truthfully, and subjective comments or guesses are not allowed.
● Those who still need diagnosis and treatment for important injuries in other departments unrelated to the undergraduate course are described in another article. 4) Past medical history ● Generally healthy or strong or weak.
● Chronological history of acute infectious diseases. Record the occurrence time, treatment results and complications of the disease.
If there is no history of infectious diseases, it is necessary to record the infectious diseases that have not occurred related to the current condition for reference. If you have herpes zoster, ask if you have a history of chickenpox. ● Whether you have been vaccinated, its type and the date of the last vaccination.
● Ask about diseases according to the system, including five senses, respiratory system, circulatory system, digestive system, urogenital system, blood system, neuropsychiatric system, motor system (muscles, bones and joints), history of trauma, surgery, poisoning and drug allergy. ● The names of allergic drugs should be written in black with character borders.
After the electronic medical record is printed, the doctor draws a red line under the drug name with a red pen. If you are allergic to penicillin, write "allergic to penicillin" 5). Personal medical history ● Birthplace and experience Pay special attention to natural foci and epidemic areas, indicate the year of migration, and indicate the specific foci or water sources, such as whether there is a history of early contact with blood-sucking diseases.
● Living habits include eating habits, alcohol and tobacco hobbies. ● Past and present occupations and their work conditions, including the time of enlistment or work, arms or types of work, positions, contact history with toxic substances, radioactive substances and patients with infectious diseases.
● Menstrual history: the number of days between menstruation and the duration of menstruation, and the age of amenorrhea can be expressed in the following simple ways: menarche age, menstrual interval days, amenorrhea age or menarche age (menstrual interval days)/(menstrual interval days) or amenorrhea age can be described in language, for example: 16 3~4 30~32 48 or electronic medical records can be described in language. Attention should also be paid to whether there is pain during menstrual cramps.
● Marital status and production history: When did you get married? Your spouse's health status, if dead, please explain the cause and year of death, whether the delivery is normal, whether there is a history of premature delivery or abortion, birth control and sterilization. ● History of smelting tour For suspicious patients, foreign guests and those who have been abroad for more than half a year, they should be asked whether they have a history of cleanliness.
6) Family history ● Health status of father, mother, brother, sister and children. If dead, explain the cause of death.
● If diseases caused by genetic factors and life contact factors are suspected, ask whether there are similar patients in the family. Note: The past history, personal history and family history of readmission can be simplified if there is nothing special.
7) Physical examination ● General conditions: temperature, pulse, pulse condition, breathing (frequency and depth), blood pressure, height and weight (if necessary); Development (normal, abnormal, poor); Nutrition (good, medium, poor, emaciated, obese); * * * and posture (such as flexion, tilt, etc.). ), complexion (such as ruddy and dull, etc. ); Expression (anxiety, pain, chronic diseases); Consciousness (awake, sleepy, semi-coma, coma) and speech state (clear, fluent, answering questions to the point), cooperation during the exam, etc. ● Skin color (normal, flushing, cyanosis, yellow staining and pallor), elasticity and presence of edema, sweating, purpura, rash, pigmentation, vascular spiders, scars, wounds, ulcers and nodules; And clearly describe its location, size and degree.
● Whether the lymph nodes are swollen all over the body or locally (submandibular, behind the ear, neck, clavicle, armpit, groin, etc.). ), should indicate the size, quantity, hardness, tenderness, adhesion; Whether the local skin has red fever, fistula or scar.
2. Inpatient medical record writing: Chinese medicine (integrated traditional Chinese and western medicine) medical record writing: inpatient medical record writing: name:. Gender: Male Age: 5 years old Nationality:. Place of birth:. Marital status: unmarried occupation:. Unit:. Postal code:. Permanent address:.
Admission time: April 2002 1310; Time of medical history collection: April 2002 1310; Narrator of medical history: reliability of children's mother: basically reliable onset solar terms: chief complaint: repeated fever and cough for 5 days after Tomb-Sweeping Day; Past history: Peripheral children began to have fever and cough with no obvious cause 5 days ago. 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. Physical examination T 37℃ P 92 times/minute R 20 times/minute bp overall situation: looking at God: conscious, tired, normal expression.
Look at the color: normal face, white color. Appearance: normal development, average nutrition, thin body.
Posture: * * Normal, natural posture and normal gait. Voice: The language is clear and moderate, with no abnormal sounds such as burping, belching, wheezing and * *.
Smell: no special smell. Tongue image: red tongue with white fur.
Pulse condition: pulse floating number. Skin, mucosa and lymph nodes: skin mucosa: skin mucosa has no yellow staining, normal texture and elasticity, slight heat, no sweat, no macula, sores, scars, tumors, abnormal acupoint signs, vascular signs, spider nevus, pigmentation, etc. 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: Chest: 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.
* * *: 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 and 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 vessel: artery: 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: the abdomen is symmetrical, the size is normal, the respiratory movement is normal, and there are no swelling, depression, rash, pigmentation, stripes, scars, umbilical hernia, varicose veins and 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.
Two yin and two excrement: two yin: the front and back yin are normal. Excrement: not checked.
Spine limbs: spine: physiological curvature exists, without deformity, rigidity and tenderness, with unlimited range of motion, and without tension and tenderness of muscles on both sides. 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: sensation: 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.
Shallow reflex: Abdominal wall reflex and plantar reflex are normal, but testicular reflex and * * * 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. Syndrome differentiation basis: According to the combination of four diagnosis methods, this disease belongs to the category of cough in traditional Chinese medicine, and the syndrome belongs to wind-heat type.
Perinatal children are young and have lung qi.
3. What is a medical record composition (for example)? It is a way for doctors to write medical records for patients. It is characterized by novel form, humorous language and eclectic structure. It can be used to criticize the current shortcomings, expose the inside story and express the mind. However, if you want to use this style in the exam, you should practice more at ordinary times. Because the medical records are too far away from our students' lives after all. Name of Wang Xiaocheng Medical Report: Wang Xiaocheng Gender: Male Occupation: Student Case: My parents complained that I was five years old. One afternoon, my mother gave Wang Xiaocheng a big red apple. A classmate said he would trade his big porcelain cat for an apple, but he forgot to bring it. He promised to bring it the next day and the patient gave it to that classmate. The next day, the patient asked. The patient was also beaten. Diagnosis: a typical new disease at the beginning of this century-mental insufficiency. Viewpoint: Parents should teach their children more profound life skills. For young patients, they can first teach some basic methods to navigate the rudder according to the wind direction. Prescription: Smart mind, 50 boxes. Bunao Zengzhi Oral Liquid, 70 boxes. When I first got involved in the world (for children), Fang and Yuan. The patient was stumped by a difficult problem. At this time, a paper ball flew to the patient's feet, and Xiaoling, a friend in the aisle, squeezed her eyes. The patient picked up the paper ball and looked at it, which was just the answer of "getting in the way". The patient reported Xiaoling's answer without hesitation. As a result, Xiaoling was punished and the patient was beaten again. Diagnosis: mental retardation is seriously aggravated. Opinion: Parents should teach by example and be tactful. During the summer vacation, parents had better take patients to participate in social "exercise". Prescription: 50 boxes of Jiannaoling, 80 boxes of Jiannaoyizhi oral liquid, introduction to advantages and disadvantages, prescription and circle. Three patients complained that they were 17 years old. They were sophomores. The patient went home on holiday, and the Lu Yu car thief bravely caught the thief alone in full view. Suggest bringing a clever daughter-in-law (Take honesty as the topic or the environment as the topic. ) Comments: The form of case diagnosis is humorous. The three medical records represent pre-school, primary school and middle school. Wang Xiaocheng is honest and upright, but he is blocked everywhere. The more honest, the more unlucky, so he was diagnosed as "a typical new disease at the beginning of this century-mental disability." .
4. What is the composition of medical record style (for example)?
This is a writing style in which doctors write medical records and articles for patients. It is characterized by novel form, humorous language and eclectic structure. It can be used to criticize the current abuses, expose the inside story and express one's own ideas. But if you want to use this style in the exam, you should practice more in peacetime, because the medical records are too far away from our students' lives after all.
Wang Xiaocheng's medical report
Name: Wang Xiaocheng Gender: Male
Occupation: Student Case: Fool
one
My parents complained: I was five years old. One afternoon, my mother gave Wang Xiaocheng a big red apple. A classmate said he would trade his big porcelain cat for an apple, but he forgot to bring it. He promised to bring it the next day and the patient gave it to that classmate. The next day, the patient asked for a big porcelain cat. People said it was nothing like that and beat the patient up.
Diagnosis: A typical new disease at the beginning of this century-mental disability.
Viewpoint: Parents should teach their children more profound knowledge about the world. For young patients, we can teach them some basic sail before the wind methods first.
Prescription: 50 boxes of brain-strengthening and intelligence-improving, 70 boxes of brain-strengthening and intelligence-enhancing oral liquid, and comic books for children, Fang and Yuan.
two
Patient private prosecution: 12 years old. The sixth grade of primary school. The patient was stumped by a difficult problem in the entrance examination. At this time, a paper ball flew to the patient's feet, and Xiaoling, a friend in the aisle, blinked. The patient picked up the paper ball and looked at it, which was just the answer of "getting in the way". The patient reported Xiaoling's answer without hesitation. As a result, Xiaoling was punished and the patient was beaten again.
Diagnosis: Mental retardation is becoming more and more serious.
Viewpoint: Parents should set an example and be euphemistic. It is best for parents to take patients to participate in social "exercise" in summer vacation.
Prescription: Brain Tong Ling, 50 boxes; Bunao Zengzhi oral liquid, 80 boxes; Introduction to advantages and disadvantages; Prescriptions and circles.
three
Patient's private prosecution: 17 years old, sophomore. When the patient went home on holiday, a car thief in Lu Yu bravely caught the thief alone, and he was stabbed many times in full view.
Diagnosis: Lack of mind is a terminal disease.
Opinion: In order to continue the royal family's incense, it is suggested to marry a smart wife. (Take "Honesty" as the topic or "Environment" as the topic)
Comments: Case diagnosis is humorous. The three medical records represent pre-school, primary school and middle school. Wang Xiaocheng is honest and upright, but he is blocked everywhere. The more honest, the more unlucky, so that it was diagnosed as "a typical new disease at the beginning of this century-mental disability." Is Wang Xiaocheng sick, or are parents, doctors and society sick?
5. My medical record diagnosis composition 1. Know yourself 1. I am a good boy (girl) 2. My food, clothing, housing and transportation 3. My medical record diagnosis (self-dissection under the desk lamp) 4. My role in (family, class, group) ...) 5. Next time, I will make my debut. I am proud of myself. I can help. I've become two, caring about my family 1, happy weekend (difficult weekend) 2, I'm in charge today 3, it's difficult for children to do housework 4, parents are (not) happy today 5, family anecdote records 6, a warm moment 7, I'm a little too official (writing a brief history of the family) 8, living within our means-about family income and expenditure. The sky is bright. Let's go to school. 4. I live in (a small town, a small mountain village, a residential area ...) 5. My hometown (vegetables, fruits, flowers, bamboo ...) 6. On holidays, we go to (picnics, outings, explorations, outings, fishing) to reflect the moon in Santan 6. Walk on Sky Street 7. I have (wings, antlers, etc.). ) 8. A strange idea of mine. Understand others 1. I told a beautiful lie 2. It's not easy for my parents. He is cute, too. Forgiveness is pistachio. Why not race with the bull? You can say anything you want. Please accept my comfort.
6. How to write a medical record Section 1 General requirements and precautions for medical record writing
1. The admission records of newly admitted patients are carefully written by residents. If there are interns, in addition to the admission records, the intern system will be written into the hospital medical records. Admission records cannot replace admission records. In the process of medical history inquiry and physical examination, residents should guide interns.
2. Admission medical records and admission records should be written after comprehensive analysis and processing after taking medical history and physical examination. All contents and figures must be reliable, concise and to the point, avoiding vagueness, generality and subjective assumptions; Positive findings should be described in detail, and negative materials with differential diagnostic value should also be included. Symptoms and signs should be recorded in medical terms, not in diagnostic terms. If the patient mentions that the patient's disease has not been diagnosed before, put the name of the disease in quotation marks. For diseases related to this disease, the symptoms and diagnosis and treatment should be indicated. The date (or age) and place of occurrence of various facts should be as clear as possible, and the onset time of acute diseases should be inquired in detail.
3. Admission medical records and admission records, in addition to focusing on medical history, signs, laboratory tests and other inspection results closely related to the specialist, we should also pay attention to the records of patients' non-undergraduate injuries and treatment. All unhealed injuries, regardless of long-term medical history, should be included in the current medical history; Only those who have recovered or have not relapsed for a long time can be included in the past medical history. In the diagnosis, we should also list the names of the injuries that currently exist and are still recovering.
Patients transferred or readmitted to other hospitals should be regarded as newly admitted patients. Those transferred from other departments should be written in. Those transferred from different wards or wards of the undergraduate course only need to make necessary records and supplements in the course record.
4. Admission medical records and admission records should be completed as far as possible before the attending physician rounds the next morning, and should be completed within 24 hours after the patient is admitted to the hospital at the latest. If the patient is seriously ill and cannot complete the medical record within 24 hours, a detailed course record must be completed in time; When circumstances permit, the admission medical records can be supplemented. When the number of people admitted to the hospital is large, the time for completing the medical record shall be stipulated by the chief physician as appropriate.
5. Except for obstetrics and a large number of patients with similar diseases admitted to hospital, tables should not be used instead of medical records; If it is necessary to use tabular medical records, it must be approved by the dean.
6. The names and numbers of disease diagnosis and operation shall be based on the International Classification of Disease Names published by the International Health Organization (latest edition), which is convenient for statistics and analysis. The English-Chinese Medical Vocabulary (published by People's Medical Publishing House) shall prevail for the time being. If the names of diseases and individual nouns have not been properly translated, the original text or Latin can be used.
7. Complete medical record template (medical record example 2: complete medical record) Name xxxxxxxxx, Department of Tuberculosis, Hulunbeier Second People's Hospital * * Sex male, female age: xx years old Marriage: already, √ unborn xx Autonomous Region (province, city) x x Banner (county) Nationality: xx work unit or address xx occupation xx Admission date: 200x, XX, XX, XX. The medical history of XX, XX, XX, XX, XX, XX, XX, XX, XX, XX, XX, XX, XX, XX (the above items are the same as the hospitalization records) refers to the medical history of chronic cough, expectoration, hemoptysis, chest pain and asthma of respiratory system.
Whether you have a history of palpitation, shortness of breath, cyanosis, edema, chest pain, syncope, hypertension, etc. Xiaohua system has a history of appetite change, belching, acid regurgitation, abdominal distension, abdominal pain, diarrhea, constipation, melena and jaundice.
Urogenital system: any history of frequent urination, urgency, dysuria, hematuria, dysuria, low back pain, edema, etc. Endocrine system and metabolism: have a history of chills, heat, excessive sweating, abnormal appetite, emaciation, dry mouth, excessive drinking and polyuria, and a history of personality, weight, hair and secondary sexual characteristics changes.
Hematopoietic system: any history of fatigue, dizziness, bleeding spots on skin or mucosa, ecchymosis, recurrent nosebleeds, gingival bleeding, etc. Nervous system: Do you have any history of headache, dizziness, insomnia, lethargy, disturbance of consciousness, convulsion, paralysis, convulsion, personality change, visual impairment, sensory abnormality, etc.
Motor system: whether there is a history of numbness, disease, spasm, atrophy and paralysis of limb muscles, whether there is a history of joint swelling and pain, dyskinesia, trauma and fracture. The medical history of the Second People's Hospital of Hulunbeier City continued p:xx subject xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
General situation: development (normal and abnormal), nutrition (good, moderate, poor), * * (autonomous, passive, forced or uneasy), gait, face and expression (acute and chronic diseases, painful expression, anxiety, fear, quietness), consciousness (clear, vague, sleepy, coma), and whether you can get along with doctors. If yes, the location, scope (size) and shape should be described. Lymph nodes: whether there is swelling (location, size, number, tenderness, hardness, mobility, fistula, scar, etc.). ) in systemic or local superficial lymph nodes.
Head: shape, hair (quantity, color, distribution, baldness, alopecia areata). Eyes: eyelid (edema, movement droop), conjunctiva (congestion, hemorrhage, pallor, edema), sclera (yellow staining), cornea (transparent, opaque, reflective), pupil (size, shape, symmetry, response and adjustment to light).
Ear: hearing, deformity, secretion and tenderness of mastoid process. Nose: whether there is deformity, alar flap, secretion, bleeding, obstruction and tenderness in the paranasal sinus area.
Mouth: bad breath, saliva secretion, lip (deformity, color, herpes, chapped, ulcer, deviated mouth), tonsil (size, congestion, secretion, false membrane), (shape, tongue quality, tongue coating, ulcer, exercise, tremor), throat (color, clear pronunciation or hoarseness, wheezing, loss of voice)
Chest: chest (symmetry, deformity, local uplift or collapse, tenderness), breathing (frequency, rhythm, depth), whether there is abnormal pulsation or varicose veins. * * * The disease description refers to the inspection requirements of * * *.
Lung: visual diagnosis: respiratory movement (bilateral comparison), respiratory type, whether intercostal space is widened or narrowed. Palpation: tremor, respiratory movement, pleural friction and subcutaneous torsion.
The second people's hospital of Hulunbeier City, the continuation page of medical history subject xxxxxxxxxxxx hospitalization number percussion: percussion sound (unvoiced, voiced, real sound, unvoiced or drum sound), lower lung boundary, activity. Auscultation: Breathing sounds (nature, strength, abnormal breathing sounds), dry and wet rales and pleural friction sounds, voice conduction (pay attention to symmetrical parts), etc.
Heart: visual diagnosis: apical pulsation (position, range, intensity), accompanied by unintentional anterior uplift. Palpation: apical pulsation (nature, location, range and intensity), tremor (location and duration) and pericardial fricative sound.
Percussion: The left and right voiced boundary (relative voiced boundary) of the heart is expressed by the distance between the center lines of ribs, and the distance from the center line of clavicle to the front center line is indicated in the table, as follows: right (cm) left intercostal (cm) XX II XX III XX IV XX IV XX V XX center line of clavicle is xx cm away from the front center line. Auscultation: heart rate, heart rhythm, heart sound (intensity, division, comparison of peripheral vascular signs of p2 and a2: whether there is capillary pulsation, beating sound and water pulse.
Abdomen: optic nerve rash: appearance (symmetrical, flat, swollen and sunken), whether there are rashes, stripes, scars, lumps, varicose veins (if any, record the blood flow direction) and gastrointestinal peristalsis waves. Palpation: abdominal wall tension, tenderness, rebound pain, fluid tremor and mass (position, size, shape, hardness, tenderness, pulsation and activity).
Abdominal circumference should be measured when there is ascites or abdominal mass. The size, texture, surface, edge, tenderness and pulsation of the liver (the right lobe is represented by the number of centimeters from the midline of the right clavicle to the lower edge of the liver, and the left lobe is represented by the number of centimeters from the xiphoid process to the lower edge of the left lobe of the liver).
Whether there is tenderness in the renal area and ureter tenderness point, and whether there is swelling in the bladder. Continuation page of medical history of the Second People's Hospital of Hulunbeier xxxxxxxxxxxx Percussion: Is there any percussion pain, dynamic voiced sound, drum sound and kidney area in the liver voiced boundary and liver area?
Auscultation: bowel sounds (normal, enhanced, weakened or disappeared), whether there is water vibration sound or vascular murmur. External genitalia and * * *: No special circumstances are left unchecked; If there are special circumstances, check them carefully and indicate the relevant situation.
If it is necessary to do gynecological examination for female patients, male doctors must have female medical staff.
8. The ingredients are indicated on the medical record. There is a prescription on the medical record. The first bud in early spring, new lotus and yellow daisy, did not fall to the ground until the first snow.
You can't meditate if you drink it in one gulp. The drug detonator is your fragile beating heart. You don't need to hold it out, just let it close its eyes and take a deep breath of fragrance, and it will disperse in the four seasons. Only in this way can your blood flow freely. Since the birth of a baby, you have been delicate since childhood, and the salt in your tears has scabbed in your hands. Finally, I made a broken palm pattern in early spring to separate the future love and affection from the cold spring. The wind is blowing from afar, and this year I left without kissing the small tree with a bent neck. You got your first medical record from the unhappy nurse, "Melancholy, apathy, acrophobia suggest traveling far away". With your head down, you gently drifted thousands of miles away, even forgetting the fallen leaves before sweeping the grave. The train lost a vague back, and you began to gain weight. The endless fat is settled in an empty corner and the silent lotus of old movies. A pile of muddy water flies into your eyes, and you are painful and blind, like a restless bird on the branch. The middle-aged man with glasses is dancing like a dragonfly in your medical record. "Mild blindness, sleepwalking, daydreaming, obsessive-compulsive disorder and delusion indicate the need for rest." You walk into a garden blankly. There is an old cane chair, and there are no small yellow flowers in Nanshan Garden. You dare not look at the yellow flowers in the mirror, trim your eyebrows, apply powder, and nourish the chapped loss. A boy with smaller wrinkles than you, expressionless, took out a blue ballpoint pen from the coat pocket of a white coat. It is not as thick as a pen. "Lack of iron and calcium means sunbathing regularly." In late autumn, the sunshine is gentle and delicate, rosy, and the eyes are shining, but the mind and hair are missing. You took the prescription. It was given to you by the old man in the blood donation car. He is talkative and is the first bud of a good father in early spring.
He said that if you drink it in one gulp, the medical record will be invalid.