Chinese medical record writing

Recommended answer 2010-8-1318: 40 Name: Hu. . Gender: Female

Age: years old Nationality: Han nationality

Marital status: divorced birthplace: Tianjin

Occupation: Retirement Admission Time: 20 10-05- 19 9:30.

Solar term of onset: record time in long summer: 20 10-05- 19 9:30.

Statement of medical history: the medical history of patients and their families should be confirmed and signed;

Chief complaint: peritoneal dialysis for 2 years, edema of both lower limbs for 2 months, aggravation of chest tightness, and difficulty in lying down 1 day.

Current medical history: The patient was admitted to our hospital two years ago due to fatigue and poor attendance. Renal function showed: Cr:1040 umol/lbun: 58.96 mmol/l co2cp:10.7 mmol/l: renal parenchymal damage, renal atrophy and right renal cyst. Peritoneal dialysis catheterization and renal replacement therapy were performed. After intermittent outpatient reexamination and regular dialysis, the condition was stable. 1.5 years ago, the patient suffered from edema of face and lower limbs after a cold, accompanied by chest tightness and suffocation, and was admitted to hospital for treatment. During the hospitalization, he was treated with integrated traditional Chinese and western medicine. Traditional Chinese medicine mainly focuses on clearing heat and resolving phlegm, promoting blood circulation and removing blood stasis, while western medicine mainly focuses on peritoneal dialysis to control blood pressure, enlarge crown, correct anemia and correct calcium and phosphorus metabolism disorder. During the period, the cerebral infarction recurred, and symptoms such as unconsciousness, lethargy, and unfavorable speech appeared. His condition was critical and his life was dying after discharge. The patient received intermittent outpatient treatment and regular dialysis. 1 year ago, the patient suffered from edema of face and limbs after fatigue and was admitted to the hospital from the outpatient department. During hospitalization, blood pressure was controlled, crown was enlarged, anemia and calcium and phosphorus metabolism disorder were corrected, and the condition was discharged stably. After intermittent regular treatment in outpatient department, the condition was stable. More than 6 months ago, the patient suffered from chest tightness and suffocation. He was admitted to our hospital for further systematic treatment. During hospitalization, he received peritoneal dialysis, blood pressure control, crown expansion and anemia correction. He was discharged after his condition stabilized. Two months ago, the patient developed edema of both lower limbs, and the edema gradually worsened in the last four days, accompanied by chest tightness and suffocation. Rt: RBC: 3.51.1.012/l, HGB:1.03g/l; Biochemical examination: urea (urea): 8.55 mmol/L, creatinine (CREA): 6 16.80 umol/L This morning, the chest tightness was aggravated and it was difficult to lie down. In order to make further systematic diagnosis and treatment, I went to the outpatient department of our hospital and lived in our department. Symptoms: lucid mind, poor mental health, fatigue, chest tightness and suffocation, edema of both lower limbs, heavy drowsiness, anorexia, insomnia, anuria, loose stool, pale tongue with white fur and weak pulse.

Past history: chronic nephritis for more than 40 years, chronic renal failure for 2 years, high blood pressure for more than 65,438+00 years, and the highest blood pressure of 230/65,438+0.30mmhg. On weekdays, Paixintong and Betaloc were taken, and the blood pressure was controlled at 65,438+0.40-65,438+0.50/90mmhg. The history of cerebral hemorrhage is more than 65,438+00 years, the right upper limb is inactive, the memory is poor, and the thyroid function declines for 65,438+0 years, denying the history of infectious diseases such as hepatitis and tuberculosis. Two years ago, he did peritoneal dialysis and catheterization in our hospital, denying the history of trauma. During my hospitalization in our hospital two years ago, I was transfused with O-type suspended red blood cells 12u due to anemia. The vaccination history is unknown.

Allergy history: Deny the history of drug and food allergy.

Family history: denying the family history of genetic diseases

Other conditions: born in Tianjin, living in Tianjin for a long time, denying the contact history of endemic diseases and epidemics, denying the contact history of epidemic areas, denying the history of tourism, denying the history of smoking, denying the history of drinking, always mild in temperament, with no special preference for diet, menarche 15 years old, menstrual period of 5 days, menstrual cycle of 28 days, menopausal age of 49 years old, married at the appropriate age, divorced without children.

To physically block an opposing player, as in ice hockey or lacrosse.

Medical examination of western medicine:

T: 36.5℃ P: 85 times/min R: 18 times/min BP: 140/ 100 mmHg.

Conscience, mental weakness, normal development, nutritional deviation, independent posture, physical examination cooperation, no yellow staining and bleeding spots on the skin and sclera of the whole body, no swelling of superficial lymph nodes, normal skull, normal pharynx, no swelling of tonsils, middle trachea, small thyroid gland, soft neck, no abnormal carotid pulse symmetry, no bulging jugular vein, no abnormal thoracic symmetry, clear voice of both lungs and thick breathing sound. The heart rate is 85 beats/min, the rhythm is regular, no pathological murmur is found in the auscultation area of each valve, the abdomen is flat and soft, the operation scar and peritoneal dialysis tube of about 6cm can be seen in the lower abdomen, there is no tenderness or rebound pain, the liver is not up-to-date, the spleen is not up-to-date, the bowel sounds are normal, no gastrointestinal morphology is seen, there is no percussion pain in both kidneys, there is no deformity in the spine and limbs, the right upper limb is inactive, the lower limbs are edema, and the front and rear yin are not checked.

Physical examination of Chinese medicine:

Conscience, listlessness, mental fatigue, chest tightness, edema of lower limbs, lethargy, anorexia, insomnia, anuria, poor stool, pale tongue with white fur and weak pulse.

Auxiliary inspection:

20 10-5- 15 blood test in the First Affiliated Hospital of Tianjin University of Traditional Chinese Medicine RT: RBC: 3.51.1012/L, HGB:103g/L;

Biochemical examination: urea (urea): 8.55 mmol/L, creatinine (CREA): 616.80umol/L.

Preliminary diagnosis: TCM diagnosis: renal failure

Syndrome diagnosis: Deficiency of both spleen and kidney, turbid toxin.

Western medicine diagnosis: chronic renal failure (uremia peritoneal dialysis)

Renal anemia

Renal hypertension

cardiac failure

coronary heart disease

myocardial ischemia

hypertension

hypothyroidism

Sequela of cerebral hemorrhage

Dialectical basis:

Because the spleen and kidney are weak, water and dampness cannot be transported, dampness is blocked, qi is blocked, and blood circulation is blocked, resulting in qi stagnation and blood stasis; After a long time, the pathogenic dampness changed from heat to dampness, and the stagnation of damp-heat blocked the qi movement, which damaged the spleen and kidney qi and yin, and the lifting and opening were abnormal. The clear one is discharged without ascending, while the turbid one cannot be discharged and stays in the body; If the damp pathogen does not go away for a long time, it will turn into turbid poison, damage the viscera, consume qi and blood, lead to deficiency of qi and blood in the viscera, and eventually lead to renal failure.

Western medicine diagnosis basis:

1, medical history: history of hypertension 10 years or more, with the highest hypertension of 230/ 130 mmHg. Taking Paixintong and Betaloc on weekdays, the blood pressure was controlled at 140- 150/90 mmHg, denying the history of diabetes for more than 40 years and chronic nephritis for 2 years.

2. Symptoms: peritoneal dialysis for 2 years, edema of both lower limbs for 2 months, and chest tightness for 4 days.

3. Physical examination: blood pressure: 140/ 100 mmHg. Breathing sounds in both lungs are thick, wet rales can be heard in both lungs, the heart boundary is not large, the heart sound is normal, the heart rate is 85 beats/min, and there is no pathological murmur in the auscultation area of each valve. The abdomen is flat and soft, and there are about 6cm surgical scars and peritoneal dialysis tubes in the lower abdomen, without tenderness.

4. Physical and chemical examination: 20 10-5- 15 Blood examination in the First Affiliated Hospital of Tianjin University of Traditional Chinese Medicine RT: RBC: 3.51.10/2/L, HGB:100. Biochemical examination: urea (urea): 8.55 mmol/L, creatinine (CREA): 616.80umol/L.

Differential diagnosis of TCM:

This disease belongs to the category of renal failure and should be distinguished from weakness. Both are mainly due to the lack of positive energy. Renal failure is mainly caused by kidney damage due to long-term illness, or by prolonged nephropathy, spleen renal failure, which leads to retention of body fluid, dampness and blood stasis in the body, turbidity and toxicity, mainly manifested as lack of positive energy, soreness of waist and knees, loss of appetite, pallor and dizziness. The patients with physical weakness mainly suffer from visceral loss, deficiency of both qi and blood, deficiency of both yin and yang, and fatigue for a long time. The main manifestations are deficiency of the five internal organs, manifested as physical and mental decline, emaciation, lack of meat, anorexia, palpitation, shortness of breath, spontaneous sweating, night sweats, gaunt face, or five upset and hot, or cold limbs and weak pulse. The patient was diagnosed as renal failure by comprehensive pulse condition and four diagnosis combined with reference.

Western medicine differential diagnosis:

This disease belongs to the category of chronic renal failure and should be distinguished from acute renal failure. Both of them are abnormal renal function, but chronic renal failure occurs on the basis of various chronic renal parenchymal diseases, develops continuously, seriously damages renal parenchyma and slowly decreases renal function. Acute renal failure often causes acute renal failure, especially long-term shock, nephrotoxicity and acute severe intravascular coagulation. , resulting in a sudden drop in urine volume, low urine specific gravity, creatinine clearance rate decreased by more than 50%. According to the patient's medical history, symptoms, signs and physical and chemical examination, it can be distinguished as chronic renal failure.

Diagnosis and treatment plan:

1, secondary health care

2, nephrology nursing routine, peritoneal dialysis nursing routine

3. Low-salt and low-fat diet

4. Negative ion air therapy (1/ day)

5. Ultraviolet disinfection of sickbeds (1/ day)

6. Remember the amount of access

7, blood pressure measurement (2 times/day)

8. Leave the catheter in the body.

9, improve the admission examination, check the automatic analysis of multi-channel electrocardiogram.

10, the main treatments are peritoneal dialysis, crown enlargement, hypothyroidism correction, hypotension, anemia correction and symptomatic treatment.

Peritoneal dialysate 2000 ML peritoneal dialysis Tid[ provided by the hospital]

Peritoneal dialysate X2000 ML peritoneal dialysis Qd[ provided by the hospital]

Isosorbide mononitrate sustained-release tablets 60 mg orally, once a day [provided by the hospital]

L-thyroxine sodium tablets 25 micrograms, oral, once a day [provided by the hospital]

Folic acid tablets 10 mg oral Tid[ provided by the hospital]

Eszolam tablets 2mg oral Qn[ provided by the hospital]

Zolpidem tablets X 10 mg oral Qn[ provided by the hospital]

Nifedipine controlled-release tablets X30 mg oral Bid[ provided by the hospital]

Valsartan capsules 80 mg orally, once a day [provided by the hospital]

Sodium bicarbonate tablets 1 g oral Tid[ provided by the hospital]

This is the format of hospital medical records. Outpatient medical records are relatively simple, write the date.

As long as the chief complaint, present medical history, past history, other supplements and physical examination are necessary, Chinese medicine decoction, Chinese patent medicine and western medicine (usage and dosage). Do it.