Chapter 1685： The medical record is too rough

"Zheng boss, you look at the test sheet." The little doctor carefully turned the iron medical record clip to the position of the paste test, and gave it to Zheng Ren, and then reported the medical history.

"The patient was treated in our hospital for 4 hours of abdominal pain 5 days ago. The diagnosis was acute appendicitis. The appendectomy was performed in the emergency department.

During the operation, it was found that the inflammation of the appendix was not typical, and the appendix was successfully removed. After the operation, the patient still felt abdominal pain. After a few hours, abdominal distension occurred. Because it was tolerable, it was not taken seriously, and it was not treated specially. After that, the abdominal distension gradually increased and the abdominal pain gradually decreased. ”

"Wait a moment, during the operation, I saw that the yellowish exudate 20 was sucked out. Did you follow the surgery?" Zheng Ren did not directly look at the test list, but found the surgical record.

After glanced at it, Zheng Ren saw a sentence that made him doubtful.

"Zheng boss, I followed the surgery." The little doctor said: "There was a small amount of pale yellow exudate coming out when the peritoneum was cut during surgery. I used a suction device to **** it clean. There is no pus, the exudate is also Clearer, not turbid."

He thinks that Zheng Ren has some big problems, just a little exudate, which may be caused by inflammatory exudation of the appendix.

Although the exudate is more, it can be estimated that only 20, it seems that nothing is worth making a fuss.

This is not the point, the main condition is the intestinal obstruction in the back and a large amount of peritoneal effusion.

But before he even reported, Zheng boss interrupted his own words.

"Well, I think about it again, you continue." Zheng Ren looked at his medical record and said casually.

"After the abdominal plain film examination showed: intestinal obstruction. According to intestinal obstruction, the diet was forbidden, continuous gastrointestinal decompression, fluid replacement, etc. The patient had ventilatory defecation 3 days after operation, but the abdominal distension was persistently aggravated, and the abdomen was obvious. Bulging. After the director's consultation, it is recommended that the patient's family members go to the provincial hospital to continue diagnosis and treatment."

"Patients are now examined: clear consciousness, poor spirit, stable vital signs. Left lower abdomen tenderness positive, no rebound pain, negative r sign, liver and spleen not touched, no abdomen touched the mass, no tenderness in each ureteral tender point There is no pain in the liver and kidney area, the voice of the abdomen is cloudy, the mobile voiced sound is positive, and the bowel sounds are normal, about 4 times."

The little doctor was somewhat proud. These things were spoken casually, but they had made great efforts.

A clinician who is so serious about himself is really hard to find with a lantern.

When the tiger's body was shaken, Zheng boss was still not allowed to bow down, crying and shouting to take himself to the emperor?

It is said that Liu Xuzhi of the radiology department was invited by Zheng Boss many times to work in the Imperial City. Going to work is not counted, there are preparations!

That is the compilation of the emperor.

Liu Xuzhi can go, what can't he do?

After reporting the medical history, the little doctor himself thought of something smug.

"Past history... Li Yong, have you ever had hepatitis B and tuberculosis in your lover?" Zheng Ren asked.

"No."

The little doctor is somewhat puzzled, and the past history is not important. It’s all in the past, and there’s nothing to ask.

Hepatitis B tuberculosis has nothing to do with appendicitis.

Even tuberculous intestinal obstruction... that's how much you see. Zheng boss, this is the bone in the egg, is it because you report the medical history report?

"What surgery did you do?" Zheng Ren continued to ask.

The little doctor looked at him and looked at Li Yong.

"No..." Li Yong hesitated.

"Think about it again, caesarean section and the like are counted." Zheng Ren looked at the history of the medical history, almost nothing to say, some helpless.

The medical record was too rough, and it was eighteen streets worse than Changyue.

Then come by yourself, Zheng Ren asked.

"I haven't done caesarean section... I heard my lover say that before marriage... I had an operation more than 20 years ago, there was a tumor on the bladder, and later the diagnosis was a benign mass." Li Yong is remembering the dust. I found what Zheng Ren needed.

This is the case when the patient's family is asked about the medical history. Many of the patients' family members don't care, and they feel that they have nothing to do with the current condition. The second is simply forgotten, this is a kind of memory deviation.

Only when you find a clue, you can ask for a clear medical history.

It is really not easy to see a doctor like a crime.

"Blood?" Zheng Ren Shen Shen, "I take a look at the film."

The little doctor responded with a clear voice and inserted the standing flat piece into the reader.

The film is very simple, there is a small liquid level, just look at the film, diagnosed as intestinal obstruction, there is no problem.

But intestinal obstruction... ascites...

There is no necessary connection between these two diseases.

Zheng Ren went back and repeated the doctor's advice, a large number of ascites, the general surgery of the Xilin Town People's Hospital used conventional diuretic means.

However, the amount of urine recorded in the course record is small.

"Is the disease record recorded, is the recorded urine volume value correct?" Zheng Ren asked.

Sometimes, some doctors will ignore this and randomly write a value.

"Zheng boss, I work very seriously." The little doctor's face is a bit red. He felt that he was wronged in the past.

This is clearly the fault of the patient's family, they asked, they did not say anything. How did Zheng boss say it when asked?

Li Yong, this old and undead, nets his own eye drops!

"Well, I can see it." Zheng Renwen said.

The little doctor’s face is a little better.

“But clinical experience is not enough.”

"..."

"With 40 furosemide, the amount of urine is not much, the kidney function is still no problem, what do you think?" Zheng Ren asked.

"..." The little doctor snorted. "I noticed this, so I suggest that the patient's family take the patient to the provincial hospital."

Zheng Ren already had a guess. He smiled and said: "Go, go and take a look at the patient."

Both the small doctor and Li Yong are dewy, but seeing the patient and checking the body are normal medical procedures. The specific diagnosis should come out after reading the patient.

If Zheng boss can understand it.

If you don't understand... this possibility is also great.

The little doctor led Zheng Ren to the ward in front of him Listen to Zheng Ren and ask: "What about your director?"

"There was a meal at noon and went out to eat."

"Do you want to drink again?" Zheng Ren asked.

"It is estimated." The little doctor is also very helpless. The director of the house is just like this. When he is on holiday, he will drink when he drinks. On normal working days, there is no surgery in the afternoon, and he is willing to drink two. This is quite awkward.

However, the town-level hospital, on this virtue, everyone is similar.

When I came to the ward, the little doctor stood on the side with respect and respectfulness.

He glanced first and the belly was bulging.

Well, this is the most basic inspection. Although I didn't say it, I watched it for nearly two seconds. I was afraid that he had already begun to ponder the related condition.

Palpation, do three or five times a day, the patient's pain position actually transferred to the left lower abdomen.

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