2251 Strict medical record writing
There was nothing wrong with the patient’s clinical routine tests, including the information on medical imaging. It would be unrealistic to perform all the examinations from the beginning to the end.
“What about the bipolar disorder caused by changes in thyroid function?” Su Yun asked.
“In your own words, there’s still no way to explain Wang Zhaoming’s existence,” Zheng Ren continued to scroll through the medical records in detail.
Bipolar disorder was only one possibility, and Zheng Ren felt that the possibility of it being bipolar disorder was not high.
“Boss, why are you looking at such a big medical record in such detail?” Su Yun asked.
“The medical record was written by Zhong min. She’s more detailed.” Zheng Ren said simply.
When clinicians wrote major medical records in the past, a standard major medical record would take at least an hour to complete by hand.
Now that they had electronic medical records, many of them were optional, and it was much more convenient than handwritten medical records.
However, it was precisely because of this that many doctors would not look at the default options carefully and fill them in. After all, he had limited time every day, and there were too many things to do. He did not have enough clinical manpower, so he could just make up some unimportant things.
Zhong min was a standard internists because the former internists did not participate in surgeries, so they “spent more” time writing medical records and looking at patients than surgeons, so their medical records were relatively more detailed.
In addition, she had a delicate personality, especially after being scared by the disappearance of the magic pen’s signature. She was even more serious and harsh.
In terms of writing the medical records, Zheng Ren felt that he would never be able to catch up to Zhong min, let alone Chang Yue.
“The light reflection of the eyes is normal, and the membranes are slightly yellow. What’s the point of this, boss?” Su Yun asked.
He had already seen the test results. His levels of mental health were all normal, so he could basically rule out any diseases related to jaunty.
Moreover, there was a possibility of mental symptoms appearing due to hepatic brain disease, but the condition of the patient in front of him was a hundred thousand miles away from that.
“There’s no point in just one. The corner of his eye is 1mm red and swollen, accompanied by peeling.” Zheng Ren then looked at the other patient’s physical signs that Zhong min had described.
Su Yun did not argue with Zheng Ren. Instead, she sat at the side and read Zhong min’s medical record with Zheng Ren seriously.
Lin Yuan was very puzzled. Generally speaking, primary hospitals only dealt with the diagnosis and treatment of common diseases. Although she had never been to Sea city, she thought that it should only be a small operation.
The medical record was described in such detail that it was like a fictional literary master using concise language to describe a passer-by. It was completely meaningless!
However, boss Zheng and big brother Yun were looking at the medical records in silence. Lin Yuan had the illusion that he had missed something.
At this moment, she seemed to feel a solemn atmosphere.
His cornea and cornea were yellow, and the corner of his eye was red and swollen. What was this?
She also began to read the medical records with great concentration. Occasionally, boss Zheng’s hand would pause for a moment, but the related problems were only common and insignificant.
For example, her lips were pale, and her gums were bleeding.
This medical record was written … Suddenly, Lin Yuan had a very bad feeling.
She had seen sister Yue’s medical record before, and it was even more detailed than the one before her. It could even be said that it described everything in detail.
Would he have to write medical records like this in the future?
She could vaguely see that her future was dark. She didn’t want to sit in the office every day and write medical records. She wanted to perform surgery and become a world-famous surgeon.
Nausea, no vomiting, body weight decreasing, body weight loss of 2.3kg in one year.
The description was too detailed, and Lin Yuan’s head started to hurt.
Lin Yuan even recalled that he had seen this doctor from Haicheng write about the patient’s oral cavity ulcer and how to treat it on several surface ulcers.
The patient suspected that it was a mental illness, so what did he mean by “mouth ulcer”? Lin Yuan cursed in his heart.
Were boss Zheng’s subordinates all perverts? they were so strict when it came to writing a major medical record.
No, it wasn’t strict. This could already be described as strict.
Immediately, Lin Yuan saw the words “diet changes medical history for 3 months” in the small summary of the medical record. She was already speechless to the extreme. If she had to write every medical record like this, she would rather go home a few days later.
“Su Yun, ask Zhong min what the change in her diet means.” Zheng Ren suddenly said.
“Yes, it’s very clear. I guess it’s because chief Wang has never met such a patient before.” Su Yun said softly. She picked up her phone and dialed a number without even looking at a contact book.
Clear? What was clear!
The hair on the back of Lin Yuan’s neck stood up.
How was it clear? just what did he see that made him clear about Wang Zhaoming’s existence?
The corners of her eyes were red and swollen? Mouth ulcer? Or a change in diet.
In that instant, Lin Yuan felt a sense of powerlessness well up in his heart. The things that he had once been proud of had crumbled so quickly in front of boss Zheng and Brother Yun, the two monsters. It was so fast that it was unacceptable.
“Zhong min, you wrote the medical record that President Wang just sent over, right?”
“The medical record of the patient named han cuijuan,”
“I saw you write a change in diet. What do you mean?”
“Alright, you can tell chief Wang that there’s already some progress. I’ll tell you the diagnosis after I discuss it with the boss. “
With that, Su Yun hung up the phone.
“Zhong min said that the patient started to have a heavy mouth three months ago, and the food he eats is too salty.” Su Yun said.
“Well, the diagnosis is clear. You can’t stop with camasiping. Take 10mg of Arapin orally once a day. Vitamin B12 will be injected into the muscle 1mg a day for the first six days, 1mg a week for the next six weeks, and then 1mg a month. ” Zheng Ren said to treat him directly.
“Boss, you’re not being careful.”
“The examination still needs to be done. Do you even need to say that?”
“Let’s just check for vitamin B12 and homocystus. ” Su Yun asked.
“Yes, the blood vitamin B12 test’s positive rate is not high, so we must check for homocystus.” Zheng Ren said,”check it now. Tell chief Wang that we will wait for the results.”
Lin Yuan speechlessly watched as Su Yun made another call. He recalled the standard diagnosis for vitamin B12 deficiency.
“Boss Zheng, vitamin B12 deficiency is generally caused by giant cell anemic, tenurivolamia, and neuropsychosis.” Lin Yuan questioned in a low voice.
“Hmm, there’s another small detail. Not every patient with vitamin B12 deficiency will have tenuritis and Mega red blood cell anemia.” Zheng Ren said.
“……”
“For example, tongue inflammation is the most common, but it’s written in the diagnosis that it’s mucoinflammation of the tongue, mouth, and digestive tract. If there’s a chance, it’d be ideal to let the patient undergo a colonoscopy. “
“Ah?” Lin Yuan was stunned for a moment.
“The gastroscopy is most likely to show that there is atrophila and chronic inflammation of the stomach. 50% of the liver and 60% of the epidermis biopsy show intestinal infection.”