Chapter 2250 Strict Medical Record Writing (Leader ivanLIN Plus 3)

All the routine clinical examinations of the patient were fine, including imaging data. It is not practical at all to do all the checks from beginning to end.

"What about bipolar disorder caused by changes in thyroid function?" Su Yun asked.

"Using your words, there is still no way to explain the existence of Wang Canlan." Zheng Ren continued to slide the mouse wheel bit by bit, and carefully read the big medical records.

Bipolar disorder is only a possibility, and Zheng Ren thinks it is unlikely to be bipolar disorder.

"Boss, why are you looking at the medical records so carefully?" Su Yun asked.

"The medical records are written by Zhong Min, she is more detailed." Zheng Ren said simply.

Clinicians write large medical records. When writing by hand in the past, a standard large medical record took at least 1 hour.

Now with electronic medical records, many of them are options, which are much more convenient than handwritten medical records.

But precisely because of this, doctors will not read and fill in many default options carefully. After all, time is limited every day, there are too many things to do, and there are not enough clinical manpower, so it is enough to fool around the unimportant places.

Zhong Min is a standard internist, because in the past, internists did not perform surgery, and spent "more" time writing medical records and seeing patients than surgeons, so the writing of medical records is relatively more detailed.

In addition, her personality is still delicate, especially after being frightened by the disappearance of the magic pen signature once, she is serious and harsh.

Just talking about writing medical records, Zheng Ren thought that he would never be able to keep up with Zhong Min, let alone Chang Yue.

"The light reflex of both eyes is normal, and the conjunctiva is slightly yellow. Does this make sense, boss?" Su Yun asked.

I have seen the laboratory test sheet, and the bilirubin and other tests are normal, which can basically rule out jaundice diseases.

Moreover, hepatic encephalopathy may also cause mental symptoms, but the condition of the patient in front of him is far away from hepatic encephalopathy.

"It doesn't make sense to just one. There is 1mm redness and swelling in the corner of the eye, accompanied by peeling." Zheng Ren then saw another patient's symptoms described by Zhong Min.

Su Yun didn't hate Zheng Ren, but sat aside and read the medical records written by Zhong Min with Zheng Ren very seriously.

Lin Yuan was very puzzled. Generally speaking, grassroots hospitals deal with the diagnosis and treatment of common diseases. Although she has never been to Haicheng, she should only have some minor operations.

The medical record is so detailed, it's like a realist literary master describing a passerby with concise language, is it completely meaningless!

But Boss Zheng and Brother Yun looked at the medical records in silence, and Lin Yuan had the illusion that he must have missed something.

At this moment, she seemed to feel a solemn atmosphere.

The conjunctiva and sclera are yellow, and the corners of the eyes are red and swollen. What is the problem?

She also began to focus on reading the medical records together. Occasionally, Boss Zheng's hand would pause slightly, but the relevant places were just some minor problems that were very common and not worth paying attention to at all.

For example, pale lips, occasional bleeding gums and so on.

This medical record was written...Suddenly, Lin Yuan had a very bad premonition.

She had read Sister Yue's medical records, which were more detailed than the one in front of her, and could even be said to describe everything in detail.

I won't have to write medical records like this in the future!

She vaguely saw a dark future. She didn't want to sit in an office every day and write medical records. She wanted to perform surgery and become a world-renowned surgeon.

Nausea, no vomiting, progressive weight loss, 2.3kg in 1 year.

This description was too detailed, and Lin Yuan's head began to ache.

Lin Yuan even recalled that he had seen the doctor in Haicheng write in front that the patient had oral ulcers, several ulcers, and how to treat them.

The patient suspects a mental illness, what does it mean to write oral ulcers? ! Lin Yuan felt a sneer in his heart.

Are all the people under Boss Zheng's hands perverted? It's so strict to write a big medical record.

No, not strict, this can already be described as harsh.

Immediately, Lin Yuan saw the line "diet change medical history for 3 months" in the medical record summary. She was already speechless to the extreme, if she had to describe every medical record like this, she would rather go home in a few days.

"Su Yun, ask Zhong Min what it means to change his diet." Zheng Ren said suddenly.

"Well, it's very clear. It is estimated that Mr. Wang has never encountered a similar patient." Su Yun said softly, picked up the mobile phone, and dialed a mobile phone number without looking for the phone book.

Clear? What is clear!

The hair on the back of Lin Yuan's neck stood up all of a sudden.

How did it become clear, what exactly did Wang Canlan's existence be confirmed by seeing?

Little red and swollen corners of eyes? Canker sores? Or diet changes.

For a moment, Lin Yuan felt a sense of powerlessness in his heart. The things I was once proud of collapsed so quickly in front of the two monsters, Boss Zheng and Brother Yun, that it was almost unacceptable.

"Zhong Min, you wrote the medical records sent by President Wang just now."

"The medical record of the patient named Han Cuijuan."

"Seeing that you wrote a sentence of diet change, what do you mean?"

"Okay, tell Mr. Wang that there are already signs of this. After I discuss it with the boss, I will tell you the diagnosis immediately."

After speaking, Su Yun hung up the phone.

"Zhong Min said that the patient started to have a heavy mouth 3 months ago, and the food was too salty." Su Yun said.

"Well, the diagnosis is clear. Carbamazepine cannot be stopped, and olanzapine 10mg is taken orally once a day. Vitamin B12 is injected intramuscularly at 1mg/d for the first 6 days, then 1mg intramuscularly every week for the next 6 weeks, and then 1mg intramuscularly every month. .” Zheng Ren directly said treatment.

"Boss, it's too imprecise."

"The inspection still needs to be done, what's the point?"

"Let's check vitamin B12 and homocysteine." Su Yun asked.

"Well, the positive rate of blood vitamin B12 is not high, and homocysteine ​​must be checked." Zheng Ren said, "Check it now, tell President Wang and let's wait for the results."

Lin Yuan looked at Su Yun speechlessly and called again, recalling the diagnostic criteria of vitamin B12 deficiency in his mind.

"Boss Zheng, vitamin B12 deficiency usually manifests as giant cell anemia, glossitis, and neuropsychiatric symptoms." Lin Yuan questioned in a low voice.

"Well, there are still some small details. Not every patient with vitamin B12 deficiency will have glossitis and megaloblastic anemia." Zheng Ren said.

"..."

"For example, glossitis is the most common, but it can be diagnosed as inflammation of the mucous membranes of the tongue, oral cavity, and digestive tract. If possible, a gastroscopy can be performed on the patient, which is ideal."

"Huh?" Lin Yuan was taken aback.

"Gastroscopy is most likely to show gastric mucosal atrophy and chronic inflammation, and 50%-60% of biopsy epithelium has intestinal metaplasia."