Chinese medicine medical record writing sample

Chinese Medicine (Integrative Medicine) Medical Record Writing Sample

Hospitalized Medical Record

Name:. Sex: male Age: 5 years old Ethnicity: .　 Place of birth: .　

Marital status: unmarried Occupation: .　 Organization: . Postal code: .

Residential address: .

Admission time: April 13, 2002 at 10:00 p.m. History taking time: April 13, 2002 at 10:00 p.m.

History taker: mother of the child Reliability: basically reliable Onset of illness: after Ching Ming Festival

Complaint: recurrent fever and cough for 5 days

Present medical history: the cause of the child's illness began 5 days ago without any obvious cause, fever, cough, sputum, nasal congestion, coughing, and nasal congestion. He came to our outpatient clinic again today for further systematic treatment and was admitted to the hospital from the outpatient clinic. At the time of admission, the symptoms were: mental fatigue, fever, cough, phlegm, no shortness of breath, vomiting stomach contents once, earache, no tinnitus, dullness, poor sleep, stools are rotten, three times a day, and urination is regulated.

Past history: past health, denied history of chickenpox, measles, tuberculosis, hepatitis.

Personal history: mother had a healthy pregnancy, full-term normal delivery, first child, birth weight and height unknown. No history of asphyxia or hypoxia at birth, no pathologic jaundice, mixed feeding, supplemental food added on time, normal growth and development, normal intelligence, vaccination on time.

History of allergy: she complained of allergy to qingkailing, and denied other food and drug allergies.

Menstrual and marital history:

Family history: healthy parents. Denies family history of hereditary disease.

Physical Examination

T 37°C P 92 beats/min R 20 beats/min bp

Overall Condition:

Looking at Spirit: clear, mentally tired, with normal expression.

Looking at the color: Normal face, whitish in color.

Look at the shape: normal development, general nutrition, thin body type.

Looking at the state: normal body position, natural posture, normal gait.

Voice: clear speech, moderate speech strength, cough, no abnormal sounds such as uh-oh, belching, croup, moaning.

Odor: no special odor.

Tongue: red tongue, white moss.

Pulse: floating pulse.

Skin, mucous membranes and lymph nodes:

Skin and mucous membranes: skin and mucous membranes have no yellowish coloring, normal texture, elasticity, etc. Skin is slightly warm, no sweating, no patchy rashes, sores, scars, swellings, no signs of acupoint abnormality, vascular signs, spider nevus, hyperpigmentation, etc., and no signs of skin scratches.

Lymph nodes: peanut-sized lymph nodes can be detected in each submandibular region, with smooth surface, no pressure, good mobility and no adhesion.

Head and face:

Cranium: the skull is normal with no deformity, swelling, or tenderness; the hair is normal in sparseness, color, and distribution; there are no boils, ringworm, or scars.

Eyes: eyebrows, eyelashes, eyelids, eyeballs are normal, conjunctiva is slightly congested, sclera is not yellowish, cornea is clear, both pupils are equal in size and roundness, diameter is 2.5mm, and response to light is sensitive.

Ear: normal auricle without deformity, smooth external ear canal, no abnormal secretion, mastoid without pressure pain, normal hearing.

Nose: no deformity, septum centered, no perforation, no turbinate hypertrophy or obstruction, no abnormal nasal secretion, no pressure and pain in the paranasal sinuses, normal sense of smell.

Oral cavity: red lips and mouth, no herpes, cracks or ulcers, normal teeth, no bleeding or swelling of the gums, no herpes, bleeding or ulcers of the oral mucosa, pharyngeal congestion (++++), bilateral enlargement of the tonsils II0, and a centered palate.

Neck:

Shape: symmetrical, no abnormal masses.

Form: no resistance to tonicity, tenderness, or restriction of movement.

Trachea: centered position.

Thyroid: no enlargement or nodules.

Jugular veins: no abnormal pulsations or murmurs, no jugular vein raging, no signs of hepatic or jugular reflux.

Chest:

Thorax: symmetrical appearance, no deformity, normal rib space, no localized elevation, depression, pressure and percussion pain, no edema, subcutaneous emphysema, mass, no venous angiosis and abnormal reflux.

Breasts: normal size, no redness, swelling or tenderness.

Lungs: normal respiration, normal respiratory activity bilaterally, normal speech tremor, clear percussion in both lungs, normal lung-hepatic turbid tone boundary, lower lung boundary, and lower edge of lung mobility during respiration. Respiratory sounds were clear in both lungs, no dry or wet rales were heard in both lungs, and there were no abnormalities in voice conduction. There was no pleural friction or rales.

Heart: The apical beat was located 0.5 cm inside the left midclavicular line between the 4th and 5th ribs, with no negative apical beat or diffuse beat in the precordial region, no tremor or friction, and the left and right turbid boundaries of the heart were as shown in the right figure. The rhythm of the heart beat was complete, the heart rate was 92 beats per minute, the heart sounds were normal, and no pathologic murmurs were heard in the auscultation areas of the valves.

Vessels:

Arteries: radial artery had a regular normal frequency and rhythm with no odd pulse. There were no snatch sounds in the femoral and brachial arteries.

Peripheral vessels: no capillary pulsation sign, no shotgun sounds, no watery pulse, no abnormal arterial pulsations, Duroziez's sign (-).

Abdomen:

Visualization: symmetrical abdomen, normal size, normal respiratory movements, no bulges or depressions, no rashes, hyperpigmentation, streaks, scars, umbilical hernia, varicose veins, gastrointestinal peristaltic waves.

Palpation: the abdomen is soft, no pressure pain, rebound pain, and does not refuse to be pressed.

Percussion: drumming, no mobile turbidity and mass.

Auscultation: normal bowel sounds, no air-over-water sounds, no vascular murmurs.

Liver: subcostal not palpable, no pressure pain in the liver area.

Gallbladder: not palpable, no pressure pain in the gallbladder region.

Spleen: not palpated, no pressure pain in the splenic region.

Kidneys: no percussion pain in both kidneys, no lumbar pain.

Bladder: not palpated, no pressure points in the ureter.

Diaphragm and excretions:

Diaphragm: normal anterior and posterior diaphragm.

Excretions: not examined.

Spine and limbs:

Spine: physiological curvature exists, no deformity, ankylosis, tenderness, no limitation of motion, no muscle tension or tenderness on both sides.

Extremities: muscle strength, muscle tone are normal, no trauma, fracture, muscle atrophy. There is no redness, swelling, pain, pressure, effusion, dislocation of joints, normal mobility, no deformity, no edema, varicose veins in the lower limbs.

Finger and toe nails: finger and toe nails are red, shiny, and normal in shape.

Nervous system:

Sensation: pain, temperature, touch, tuning fork vibration and joint position are normal.

Motor: no muscle tension and atrophy, no paralysis, no abnormal movements, **** agent movement and gait are normal.

Superficial reflexes: abdominal wall reflexes and metatarsal reflexes were normal, tic reflexes and anal reflexes were not checked.

Deep reflexes: biceps and triceps reflexes, radial membrane reflexes, knee tendon reflexes and Achilles tendon reflexes were normal.

Pathologic reflexes: Hoffmann (-), Babinski (-), Gordon (-), Chaddock (-), Kernig (-).

Laboratory tests: blood analysis: WBC 12.6x10e9/L, GRAN% 76.2% .

Chest X-ray: bronchial infection in both lungs.

Based on the identification of the disease:

The four diagnoses together, this disease belongs to the category of "cough" of the motherland medicine, and the evidence belongs to the "wind-heat type". Because the child is young, the lungs are weak, for the wind and heat of the evil attack, the evil closed to the lungs, the lungs are unable to purge, the couper opening and closing inaccuracy, can lead to fever, cough. Nasopharynx is the door of the lung and stomach, and the redness of the pharynx can be seen when the wind-heat evil is felt. Lung and spleen are closely related, if the lung qi is damaged, the spleen qi is also weak, so it can cause dullness, if the stomach is out of harmony, it can cause vomiting, and if the transportation is out of order, it can cause rotting of the stools. The tongue is red, the moss is white, and the pulse is floating, all of which are signs of wind-heat.

Diagnosis in western medicine is based on:

1. Medical history: recurrent fever and cough for 5 days.

2. Symptoms and signs: fever, cough with phlegm, vomiting of stomach contents once, earache, dullness, poor sleep, rotten stools. Pharyngeal congestion (++++), double tonsils II ° large. Breath sounds in both lungs were coarse, and a few dry and wet rhonchi could be heard in both lower lungs.

3, auxiliary examination: blood analysis: WBC 12.6x10e9 / L, GRAN% 76.2%, chest radiographs: bilateral lung bronchial infection.

Admission diagnosis

Chinese medicine diagnosis: cough

Wind-heat type

Western medicine diagnosis: acute bronchitis

Intern:

Resident.