1685 The medical record is too crude.
“Boss Zheng, please take a look at the test results.” The young doctor attentively flipped the iron – made medical record folder to the place where the test was stuck and handed it to Zheng Ren. Then, he reported the medical history.
“The patient came to our hospital five days ago for four hours due to abdominal pain. He was diagnosed with acute appendicitis and was required to undergo an appendectomy in the emergency department.
During the surgery, he found that the symptoms of Appendix inflammation were not typical, and the appendectomy was successful. After the operation, the patient still felt abdominal pain, which appeared a few hours later. Because it was bearable, it was not paid attention to, and there was no special treatment. After that, the abdominal pain gradually worsened, and the abdominal pain gradually eased. “
“Wait a minute. During the operation, I saw that 20ML of light yellow ooze was sucked out. Did you follow in the operation?” Zheng Ren did not look at the test results directly. Instead, he looked for the surgery records.
With a glance, Zheng Ren saw a sentence that made him suspicious.
“Boss Zheng, I’ll be joining you for the surgery.” The young doctor said,”when I cut open the peritoneum during the surgery, there was indeed a small amount of pale yellow ooze, and I sucked it clean with a suction device.” There’s no moss, and the ooze is clear. “
He felt that Zheng Ren was making a mountain out of a molehill. It was only a little oozing, which might be caused by the inflammation of the appendix.
Although there was a lot of oozing liquid, it was estimated to be only 20ml, which was not worth making a fuss about.
This was not the main point. The main illness was intestinal obstruction and a large amount of seroperitosis.
However, before he could report, boss Zheng interrupted him.
“Yes, let me think about it. You can continue.” Zheng Ren said casually as he flipped through the medical records.
“After that, the abdominal plain film showed that it was an intestinal obstruction. According to the condition of intestinal obstruction, diet was forbidden, continuous gastrointestinal decompression, fluid replacement, and other treatments were given. Three days after the operation, the patient was relieved, but the abdominal bloating continued to worsen, and there was obvious abdominal inflation. After consultation with the director, he suggested that the patient’s family should be transferred to the provincial Hospital to continue the diagnosis and treatment. “
“The patient’s consciousness is clear, his spirit is weak, and his vital signs are stable. Yang for tenderness in the lower left abdomen, no rebound pain, and negative for Murphy sign. No contact under the liver, spleen, and ribs, no contact with the pustules in the whole abdomen, no tenderness in the ureter, no percussion pain in the liver and kidney, turbid sound in the abdomen, and positive for mobility. Normal intestinal sound, about four times per minute. “
The little doctor was somewhat proud. These things were casually said, but he had put in a lot of effort.
It was really hard to find a clinician who was as serious as he was.
Boss Zheng’s body trembled. Wouldn’t he have to bow down and cry and shout that he wanted to take him to the capital?
It was said that the coward, Liu xuzhi from the radiology department, had been invited by boss Zheng many times to work in the capital. It didn’t even count if he went to work, but there was also an establishment!
That was the establishment of the imperial capital.
If Liu xuzhi could go, why couldn’t he?
After reporting the medical history, the young doctor thought to himself proudly.
“Past history … Li Yong, did your wife have hepatitis B or tuberculosis before?” Zheng Ren asked.
“No, I didn ‘t,”
The young doctor was somewhat puzzled. Past history was not important. It was all in the past, so there was no need to ask.
Is there any relationship between hepatitis B, tuberculosis and appendicitis?
Even if it was a tuberculosis – Type intestinal obstruction … It was very common. Boss Zheng was nitpicking just because he had reported her medical history.
“Have you had any surgery?” Zheng Ren continued to ask.
The young doctor looked at Li Yong with a dumbfounded expression.
“No…” Li Yong hesitated.
“Think about it again. Things like C – sections also count.” Zheng Ren looked at the medical record, which had almost nothing to say about the past, and felt a little helpless.
The medical record was written too crudely, and it was 18 streets worse than Chang Yue ‘s.
“Then I’ll do it myself,” Zheng Ren asked.
“I’ve never done a C – Section before … I heard from my wife that before marriage … About 20 years ago, I had an operation. There was a swelling on my bladder. After the removal, it was diagnosed as a benign tumor. ” Li Yong found what Zheng Ren needed in the dust of his memory.
This was the case when asking the patient’s family members about his medical history. The patient’s family members would not care about many things, thinking that it had nothing to do with his current condition. Secondly, he had completely forgotten about it. This was a kind of deviation in memory.
Only by finding some clues and getting to the bottom of it could he get a clear medical history.
Seeing a doctor was like solving a case. It was really not easy.
“Bladder?” Zheng Ren muttered,”let me take a look at the scan.”
The young doctor responded in a clear voice and inserted the vertical abdominal x – ray film into the MRI scanner.
The x – ray was very simple, and there was a small amount of fluid in it. Just by looking at the x – ray, it was not a problem to diagnose that it was an intestinal obstruction.
However, intestinal obstruction … Seropertural effusion …
There was no definite connection between these two illnesses.
Zheng Ren went back and read the doctor’s advice again. There was a large amount of seroperitum, and the General Surgery Department of the People’s Hospital of Xilin town used the conventional method of urethritis.
However, the amount of urine recorded in the course of disease was very little.
“Is the value of urine recorded in the course of disease correct?” Zheng Ren asked.
Sometimes, some doctors would ignore this point and randomly write a value on it.
“Boss Zheng, I’m very serious about my work.” The young doctor’s face was a little red. He felt that he had been wronged by the part of his past history.
This was clearly the fault of the patient’s family. He had asked them, but they did not say anything. Why did boss Zheng just answer when he asked?
Li Yong, this old man, was giving him an eye – opener!
“Yes, I can tell.” Zheng Ren said gently.
The young doctor’s complexion improved slightly.
“But I don’t have enough clinical experience.”
“……”
“You’ve used 40mg of rapid urine, but it doesn’t seem like much. There’s no problem with your kidney either. What are you thinking about?” Zheng Ren asked.
“…” The young doctor was stunned 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,””Let’s go and take a look at the patient. “
The young doctor and Li Yong were both drowsy, but seeing the patient and checking his body were normal treatment procedures. The specific diagnosis should be made after seeing the patient.
If only boss Zheng could understand.
If he didn’t understand … The possibility was very high.
The junior doctor led Zheng Ren to the ward and heard Zheng Ren ask,””Where’s your Department Director?”
“I had a lunch appointment at noon, so I went out for lunch.”
“You want to drink again?” Zheng Ren asked.
“I guess so.” The young doctor had no other choice. His department Director liked this kind of thing, and he usually drank alcohol during the holidays. On a normal working day, even if he did not have any surgeries in the afternoon, he would still be willing to drink a few sips. This was something that made people criticize him in their hearts.
However, this was how town – Level hospitals behaved, and everyone was similar.
When they arrived at the ward, the young doctor stood respectfully at the side and watched boss Zheng’s physical examination.
He first took a look. His abdomen was swollen.
Well, this was the most basic visual inspection. Although he didn’t say it, after looking at it for nearly two seconds, he was probably already thinking about the related illness.
Palpation … He did it three to five times a day, but the patient’s pain had shifted to the left lower abdomen.