Ask for answers to the patient s medical records, and be anxious and urgent

The patient is fatigued, anorexic, abdominal distension and discomfort, emaciated, dark complexion, and spider angiomas can be seen on the face and upper chest; Itching,** and yellowing of the eyes in the last 1 week are clinical signs of liver disease. Cholestasis can cause itching, damage to liver cells can cause jaundice, and spider angiomatas are caused by liver dysfunction that inactivates estrogen. abdominal distension and discomfort, abdominal distention; Unsatisfactory palpation of the liver and spleen indicates ascites.

Combined with the progressive exacerbation of the patient's condition, the possibility of liver cancer should be considered first, and liver cirrhosis should be considered secondly.

A complete set of liver function, two and a half pairs, AFP, CEA, and abdominal ultrasonography and CT should also be checked.

The clinical significance of liver function, two to half, is well known. Liver damage, liver function is a sensitive indicator, detection of liver function can determine the degree of liver damage, two and a half can detect whether the patient is hepatitis B carrier, hepatitis B is the most important cause of primary liver cancer, but also one of the causes of liver cirrhosis. AFP is the main indicator for diagnosing primary liver cancer, and CEA is one of the indicators of gastrointestinal tract tumors, and the detection of CEA can distinguish between primary and metastatic liver cancer.

As for B-ultrasound and CT examinations, the purpose of diagnosis can be basically achieved.

Possible results: abnormal liver function (including abnormal serum enzymes, abnormal protein metabolism, inverted white globule ratio, abnormal lipid metabolism, abnormal bilirubin metabolism, abnormal bile acid metabolism, etc.), hepatic ascites, hepatic mass, two and a half may be positive, AFP and CEA may be increased. There are many ways to measure the measurement, which varies from hospital to hospital.

Most of the hospitals in two and a half pairs are the gold standard method, and the AFP and CEA are now basically using the radioimmunoassay method. These are not biochemical tests. The full set of liver function is a biochemical project, and the hospital basically uses a biochemical analyzer.

The blood tests mentioned above use serum.

Hello, what you may need is a full set of hospitalizations.

What is the condition of the internal medicine hospitalization certificate or?

Answer]: A After returning to the ward, the patient's internal abdominal drainage tube drained 210ml of bloody fluid, the pulse increased rapidly, and the blood pressure was in the normal range, but it had decreased, and intra-abdominal hemorrhage should be suspected.

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Detailed interpretation of medical records: name, gender, age, marriage, ethnicity, occupation, place of birth, current address, place of work, ID number, postal code, **, admission time, recording time, medical history narrator (indicate the degree of reliability). Fill in the requirements:

1) The age should be written "year", infants and young children should be written "month" or "day", not "become", "child", "old", etc. (2) The occupation should be written with specific job categories, such as lathe workers, unemployed, teachers, trade union cadres, etc., and cannot be written as workers and cadres in general. (3) Address:

Rural areas should be written to townships and villages, and urban areas should be written to street numbers; The factory writes; Workshops, teams, and departments are written in the organs. (4) The time of admission and the time of recording should be indicated. (5) Medical history narrator:

Adult patients are narrated by themselves; Children or delirious people should write the name of the complainant and the relationship with the patient, etc., the chief complaint: the chief complaint refers to the main symptoms and signs of the patient's admission to the hospital, as well as the time, nature or extent, location, etc., according to the chief complaint can produce the first diagnosis. The language of the chief complaint should be concise and clear, generally no more than 20 words.

Diagnosis or test results are not the main complaint (except for those who are asymptomatic). If there is more than one complaint, it may be listed separately in order of priority or time of occurrence.

Summary. There are many diagnoses in this patient: 1. Acute attack of chronic bronchopneumonia; 2. Cormonale heart distension disease; 3. Right heart failure; 4. Grade 2 hypertension; 5. Respiratory acidosis, etc.

Case Discussion Summary of Medical Records: Patient, male, 78 years old, farmer. Due to cough, shortness of breath, fever for 5 days, the whole body scattered bleeding points for 1 day.

There are many diagnoses in this patient: 1. Acute attack of chronic bronchopneumonia; 2. Cormonale heart distension disease; 3. Right heart failure; 4. Grade 2 sedan for hypertensive disease in the shed; 5. Respiratory acidosis, etc. Closed and trousers.

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Diagnosis: hepatic cyst abrupt.

Diagnosis is based on: 1) circular anechoic area of the 5th segment of the liver with clear borders;

2) the echo behind the lesion branch is enhanced, and the lateral sound shadow can be seen;

3) There was no blood flow in the lesion chain residue.

Summary. 1.Case Symptoms:

Repeated cough, sputum, wheezing for 10 years, the patient developed a cough with a little sticky sputum after a cold in winter 10 years ago. Since then, he has had cough and sticky sputum symptoms every season. 2.

Diagnostic process: dialectical basis, wind and cold are affected, contained in the lungs, and the lung qi is not declared, so chest tightness and shortness of breath, wheezing, coughing and breathing reversal. 3.

Ingredients of traditional Chinese medicine: 6g of ephedra, 15g of perilla, 10g of almonds, 6g of boiled licorice. Follow this pharmacy and take it regularly to get rid of the disease.

Traditional Chinese medicine pays attention to looking, hearing, inquiring, and taking the pulse to see a doctor. The above is a case analysis question answered by the teacher, please refer to it.

Traditional Chinese Medicine ** Case Analysis Questions.

Have a specific question, dear.

Isn't that concrete?

It's all in the spotlight right away, not specific yet?

Are there any questions like this that the teacher needs to give examples?

Symptoms: Repeated Dajingla cough, sputum production, wheezing for ten years, the patient coughed after a cold in winter ten years ago, with a little sticky sputum. Since then, he has had a cough and mucous sputum symptoms every season.

Diagnostic process: dialectical basis, wind and cold are affected, contained in the lungs, and the lung qi is not declared, so chest tightness and shortness of breath, wheezing, coughing and breathing reversal.

Ingredients of traditional Chinese medicine: ephedra 6g, perilla 15g, apricot number of people 10g, boiled licorice 6g. According to this pharmacy, the potato potato period is taken, and the medicine can be cured. The above is a case analysis question that the teacher answered, dear, please refer to it.

Traditional Chinese Medicine ** Case Analysis Questions and Answers.

1.Symptoms: Repeated cough, sputum production, air leakage and asthma for 10 years, the patient had a cough with a little sticky sputum after being cold in winter 10 years ago.

Since then, he has a dull cough and sticky phlegm symptoms every season. 2.Diagnostic process:

According to the dialectical basis, the wind and cold are affected, which is contained in the leaky lungs, and the lung qi is not declared, so the chest is tight and short, and the wheezing and coughing are reversed. 3.Ingredients of Chinese medicine:

Ephedra 6g, perilla 15g, almond 10g, boiled licorice 6g. Follow this pharmacy and take it regularly to get rid of the disease. Traditional Chinese medicine pays attention to looking, hearing, inquiring, and taking the pulse to see a doctor.

The above is a case analysis question answered by the teacher, please refer to it.