Help me write a professional cold and fever case

There are handwritten and organic typed.

Question 1: Seek outpatient medical records for colds and fevers (detailed) Department: Respiratory Medicine.

Chief complaint: cough for 3 days with fever for 1 day.

Medical history: The patient felt nasal congestion, runny nose, slight cough 3 days ago, self-medication with poor effect, chills, fever and body temperature in the past 1 day. He came to our hospital for treatment.

Examination: The patient was conscious, the throat was red and swollen, the tonsils ( ) and both lungs had clear breath sounds, there was no abnormality in cardiac auscultation, and there was no abnormality in abdominal examination. The hemogram WBC is normal, and the L is slightly higher. Yu ( ).

Treatment: ribavirin 5 tablets, 3 times a day; VC silver warp 3 times, 3 times; 15g times of indigo root, 3 times a day; 4 tablets of compound Chuanbei essence tablets, 3 times a day; Nimesulide 1 tablet should be taken when fever.

Diagnosis: upper respiratory tract infection (cold).

Question 2: How to write a cold and fever medical record Runny nose and fever for a day.

PE: Body temperature: 38°C

Febrile countenance, clear, pharyngeal congestion is marked, tonsils are not enlarged.

Heart rate: 38 beats, rhythm, clear breath sounds, no obvious rales in both lungs.

Diagnosis: 1Fever Cause?

2.Cold. Treatment: Routine blood tests.

Antiviral, symptomatic**.

r: 1.Antiviral oral solution 10ml orally 3 times a day.

2.Nishu sells mesulide dispersible tablets orally 2 times a day.

Follow-up. Doctor's signature.

Date Question 3: Fill in the case of cold and fever The patient's complaints: cough, sputum production, high fever, lack of potato, 2 days.

Physical examination: clear, slightly shortness of breath 2 heart rhythm 95 bpm, rhythm Qi, body temperature C, blood pressure 110 70 mmHg

Auscultation of the heart: coarse breath sounds in both lungs, no obvious sounds.

The onset of the disease comes from poor stomach appetite, poor spirit, two stools, and night sleep.

Diagnosis: acute upper respiratory tract infection.

rx： 1. 5% gns 500ml

Penicillin 320U vgtt bid *3d (skin test).

2.Tylenol 2 boxes of 1 tid po

3.If you feel unwell, please feel free to return to the doctor.

Question 4: Fever outpatient medical record sample 20 points The doctor did not see the patient. Who will prescribe the drug. In other words, fever can be caused by many diseases. You should go to the hospital!

Question 5: How to write cold medical records Dizziness, cough for 3 days, no fever, sore throat and other discomforts, less sputum, white sputum.

PE: degree, slightly congested pharynx, no enlargement of tonsils, clear breathing sounds in both lungs, no dry and wet rales were heard, and no abnormalities were found.

Primary diagnosis: upper respiratory tract infection.

r Complete blood count.

Chest X-ray Azithromycin.

Compound licorice tablets 3 tablets tid

Vitamin C silver warp tablets 2 tablets TID

Take breaks and drink plenty of fluids.

There is no specific medicine for colds, generally only symptomatic**, it is generally recommended to take cold and heat clearing granules, amoxicillin capsules and banlan root to **, oral drugs are not effective, it is recommended to infusion anti-inflammatory** as well, because the blood concentration of infusion is higher and the effect is faster. At present, take more rest and drink more water.

Really written: Note that the fever can be molded for two days and one day, the physique is normal, and the details are omitted.

Generally, when the baby has a cold, I don't give him medicine, I give the baby to drink Youbo milk powder, it has a variety of nucleotides, the effect of enhancing the baby's immunity is obvious, the baby can develop healthily, the nutrition is sufficient, and the immunity is improved quickly, and the cold rarely appears, you can try it.

Runny nose and fever for a day.

PE: Body temperature: 38°C

Feverish face, clear, pharyngeal congestion, and unenlarged tonsils.

Heart rate: 38 beats, rhythm, clear breath sounds, no obvious rales in both lungs.

Diagnosis: 1Fever Cause?

2.Cold. Treatment: Routine blood tests.

Antiviral, symptomatic**.

r:1.Antiviral oral solution 10ml orally 3 times a day.

2.Nimesulide dispersible tablets are taken orally 2 times a day.

Follow-up. Doctor's signature date.

patient symptoms and signs; physical examination; You give treatment: such as the tests done, the drugs used, etc., so that you can do it.

This can't be scribbled, first of all, it is written that it is related.

The basic personal information, some of which are machine-typed, some are handwritten, and secondly, how to write this is a key matter, that is, according to the specific situation, specific analysis, what kind of governance is needed. It all depends on the actual situation, and cannot be generalized, which is the basic ethics of doctors. It is necessary to do the greatest responsibility for each patient.

For example, the general one is to reduce the fever, and the more serious one is to be antiviral. Specific problems are analyzed on a case-by-case basis.

Dizziness, cough for 3 days, no onset.

Discomfort such as heat and sore throat, less sputum, white sputum.

PE: degree, slightly congested pharynx, no enlargement of tonsils, clear breath sounds in both lungs, no dry and wet rales were heard, and no abnormalities were found.

Primary diagnosis: upper respiratory tract infection.

r Complete blood count.

Chest X-ray Azithromycin.

Compound licorice tablets 3 tablets tid

Vitamin C silver warp tablets 2 tablets TID

Take breaks and drink plenty of fluids.

It's a cold medical record!! Cold Medical Records:

1. Medical records.

Main symptoms: The child's body is a little hot, the body temperature is runny nose and saliva, there are a few small red spots on the back of the head that do not protrude, and the stool is abnormal.

2. History of present illness: cold and fever, physical weakness.

Anamnesis: no history of surgery, trauma, blood transfusion, poisoning, or drug allergy.

3. Pathology report.

Pathologic diagnosis: upper respiratory tract infection.

Prescription: Pediatric Qingrening granules (three times a day, half a bag each time).

Acetylketamycin granules (one sachet twice a day, one at a time -- colds Medical record details.

Name: Abu Gender: Male Age: 25 30 years old Region: Jiangsu Province - Nanjing City.

Name of disease: cold.

Whether: Already.

Hospital: Unknown.

Drugs used: Acetylspiramycin tablets.

Vitamin B2 tablets.

Compound aminophenamine capsules (Billicon, Ren and Click, Tektronix).

Compound pseudoephedrine hydrochloride extended-release capsule (New Contec).

Plate indigo root particles.

Coptis supernatant.

Huoxiang Zhengqi drop pills.

Compound cold tablets.

Vitamin C silver warp tablets.

Medical Expenditure: RMB.

Other notes: I went on a business trip to Beijing, but I didn't expect the sky to change, plus I drank at night, I caught a cold, and I had a severe cold. My friend's Contec and Banlangen ate some of them, and I bought a box of kernels and Click, and I spent 10 yuan in the open shed, and vitamin B2 and acetylspiramycin were my standing medicines.

It didn't get better until I came back from a business trip.

I went to Simcere Pharmacy to buy some medicines to replenish the inventory at home, and the list is as follows:

Snake gallbladder Chuanbei liquid:

Compound aminophenamine capsules (kernel and click):

Huoxiang Zhengqi drop pills.

Coptis supernatant.

Vitamin C silver warp tablets.

Acetylspiramycin:

Compound cold tablets.

It is recommended that you go to the pharmacy to buy medicines, do not completely choose the drugs recommended by the salesperson, in fact, there are many drugs that are very cheap, but the pharmacy recommends those with high profits, don't get used to them, spend your own silver in vain. Exciting Mountain.