Chapter 1684 The Medical Records Are Too Rough

"Boss Zheng, look at the test sheet." The little doctor diligently flipped the iron medical record clip to the position of the pasted test sheet, handed it to Zheng Ren, and then reported the medical history.

"The patient visited our hospital 5 days ago because of abdominal pain 4 hours ago, and was diagnosed with acute appendicitis, and an emergency appendectomy was performed.

During the operation, it was found that the inflammation of the appendix was not typical, and the appendix was removed successfully. The patient still felt abdominal pain after operation, and abdominal distention occurred several hours later, which was tolerable and did not pay attention or special treatment. After that, the abdominal distension gradually increased and the abdominal pain gradually decreased. "

"Wait a minute, I said that 20ML of light yellow exudate was sucked out during the operation. Did you follow the operation?" Zheng Ren did not directly look at the laboratory test sheet, but found the operation record.

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

"Boss Zheng, I followed the surgery." The little doctor said: "During the peritoneal incision, a small amount of yellowish exudate came out. I used a suction device to suck it up. There was no pus coating, and the exudate was also Relatively clear, not cloudy.”

He felt that Zheng Ren was making a fuss, just a little exudate, which might be caused by appendicitis.

Although the exudate is relatively large, it is estimated that it is only 20ml, which seems to be nothing to make a fuss about.

This is not the point, the main disease is in the back of the intestinal obstruction and a large amount of ascites.

But before he could report, Boss Zheng interrupted himself.

"Well, I'll think about it again, you can continue." Zheng Ren said casually while flipping through the medical records.

"The subsequent abdominal plain film examination showed: intestinal obstruction. Then, according to the intestinal obstruction, fasting, continuous gastrointestinal decompression, fluid replacement and other treatments were given. The patient had ventilation and defecation 3 days after the operation, but the abdominal distension continued to aggravate, and the abdominal obviousness appeared. Bulging. After consultation with the director, it is recommended that the patient's family be transferred to the provincial hospital for further diagnosis and treatment."

"The patient's current physical examination: clear consciousness, poor spirit, stable vital signs. Left lower quadrant tenderness is positive, no rebound tenderness, Murphy's sign is negative, liver and spleen are not palpable under the ribs, no mass is palpable in the whole abdomen, and each ureteral tender point has no tenderness. , No percussion pain in the liver and kidney area, dullness on abdomen percussion, positive moving dullness, normal bowel sounds, about 4 times/min.

The little doctor is a little proud, saying these things casually, but he has put a lot of effort into it.

It is really hard to find a clinician as serious as himself.

The tiger's body shook, and Boss Zheng bowed before he could bow his head, crying and shouting to take him to the imperial capital?

It is said that Liu Xuzhi from the radiology department has been invited by Boss Zheng many times to work in the imperial capital. Going to work doesn't count, there's still programming!

That is the preparation of the imperial capital.

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

After reporting the medical history, the little doctor thought a little proudly.

"Past history... Li Yong, did your lover have hepatitis B or tuberculosis before?" Zheng Ren asked.

"No."

The little doctor is a little puzzled, the past history is not important. It's all in the past, so what is there to ask?

Hepatitis B tuberculosis has nothing to do with appendicitis.

Even a tuberculous bowel obstruction...how common is that. Boss Zheng is being picky, just because he reported his medical history, okay?

"Have you had any surgery?" Zheng Ren continued to ask.

The little doctor looked at Li Yong with a confused expression.

"No..." Li Yong hesitated.

"Think about it again, caesarean section and the like are counted." Zheng Ren looked at the past history that almost didn't say anything on the medical record, and was a little helpless.

The medical records are too rough, eighteen blocks behind Chang Yue.

Come on by yourself, Zheng Ren asked.

"I haven't had a caesarean section... I heard my wife say that before I got married... I had an operation about 20 years ago, and there was a tumor on the bladder, which was later diagnosed as a benign mass." Li Yong is in the dust of memory I found what Zheng Ren needed.

This is the case when asking the patient's family about the medical history. The patient's family doesn't care about many things, and feels that it has nothing to do with the current condition. The second is to forget it at all, which belongs to a certain kind of memory deviation.

Only by finding the clues and getting to the bottom of it can it be possible to ask for a clear medical history.

Seeing a doctor is like solving a case, it's really not easy.

"The bladder?" Zheng Ren pondered, "I'll take a look at the movie."

The little doctor gave a crisp response and inserted the standing abdominal plain film into the film reader.

The film is very simple, there is a small fluid level, just watching the film, there is no problem with the diagnosis of intestinal obstruction.

But bowel obstruction...peritoneal effusion...

There is no necessary connection between the two diseases.

Zheng Ren went back and read the doctor's order again. There was a lot of peritoneal effusion. The general surgery of Xilin Town People's Hospital used conventional diuretic methods.

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

"In the course of the disease, is the recorded urine volume correct?" Zheng Ren asked.

Sometimes, some doctors ignore this point and write a random value on it.

"Boss Zheng, I work very seriously." The little doctor's face was a little red, and he felt aggrieved in the past episode just now.

This is clearly the fault of the patient's family. I asked myself, but they didn't say anything. Why did Boss Zheng say it as soon as he asked?

Li Yong, this immortal, put eye drops on himself!

"Well, I can see it." Zheng Ren said warmly.

The little doctor's face improved a little.

"But the clinical experience is not enough."

"..."

"After using 40mg of furosemide, the urine volume is not much, and there is no problem with renal function. What are you thinking about?" Zheng Ren asked.

"..." The little doctor was startled for a moment, "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, take a look at the patient."

The doctor and Li Yong were both dazed, but seeing patients and physical examinations were normal procedures for diagnosis and treatment, and the specific diagnosis should come out after seeing the patients.

If Boss Zheng can understand it.

If you don't understand...the possibility is also very large.

The little doctor led Zheng Ren to the ward in front, and heard Zheng Ren ask, "Where's your director?"

"There's a dinner party at noon, so I went out to eat."

"Want to drink again?" Zheng Ren asked.

"I guess it is." The little doctor is also very helpless. The director of his own is like this, and he usually drinks when he is on vacation. On a normal working day, there is no surgery in the afternoon, and he is willing to drink two sips, which is quite depressing.

However, in town-level hospitals, everyone is similar in this virtue.

When I came to the ward, the little doctor respectfully stood aside to watch Boss Zheng's physical examination.

He glanced first, his belly distended.

Well, this is the most basic inspection. Although he didn't say it, but after watching it for nearly two seconds, I'm afraid he has already started to ponder the related condition in his heart.

After palpation, I did it three or five times a day, and the patient's pain actually shifted to the left lower abdomen.