How to write cases of atopic dermatitis 10

Dermatitis is a very common disease, but because many times do not know how to care, or the wrong care leads to a more serious problem, in the middle, many are allergic dermatitis, now combined with some examples for analysis.

Netizen 1: As soon as spring comes, I am susceptible to spring dermatitis, I have a lot of red rashes on my face, and I can't go out, I don't know what to do?

Expert: For spring dermatitis is generally not too serious, you can regulate it at home and relieve the symptoms. First of all, add a small amount of salt to the boiling water, adjust it to light salt water, then let it cool, put it in the refrigerator to refrigerate, wait for the water to be completely chilled, and then apply the face with a cotton pad dipped in chilled light salt water for 10 minutes every hour, which can effectively reduce the rash and allergy symptoms.

Secondly, we should pay attention to our diet, eat less hair, that is, seafood, beef and mutton, etc., and eat more vegetables, which can also reduce symptoms. If it is very serious, you will need to go to the hospital.

I'll copy the medical records of your nails later!

R1 Nail of the foot is examined to have nail moss, I request**.

The 2nd, 3rd, and 4th fingers of both feet are gray and thickened, and the middle is raised

Diagnosis: R2 general examination.

It's over, nails also belong to the ** family, I hope it helps you!

There are many factors that induce dermatitis attacks, don't take medicine indiscriminately, you can go to Zhengling Shengui Hospital for the next ** allergen test. Drink plenty of water, eat more light food, eat more fruits and vegetables that contain more vitamin C, and keep your stools smooth. Pay attention to normal work and rest, keep a happy mood, and pay attention to the balance and impact of environmental and climate changes.

Rub cases and long.

1. Admission record.

2. Ward round records.

3. Discharge records.

Section 1: General requirements and precautions for writing medical records.

1 Admission records for newly admitted patients are carefully written by the resident physician. For those who have interns, in addition to the admission records, the intern physicians will also write the admission medical records. Admission records are not a substitute for admission records.

During the history and physical examination, the resident should instruct the intern.

2 Admission medical records and admission records must be written after comprehensive analysis and processing after taking medical history and physical examination. All content and figures must be reliable, concise and to the point, avoiding ambiguity, generality and subjective assumptions; Positive findings should be described in detail, and negative materials with differential diagnostic value should be included. All kinds of symptoms and signs should be recorded in medical terms, and diagnostic terms should not be used.

If a patient mentions a previously undiagnosed patient's disease, the name of the disease should be in quotation marks. For diseases related to this disease, the symptoms and diagnosis and treatment process should be noted. The date (or age) and place of occurrence of the various facts mentioned should be as clear as possible, and the time of onset of acute illness should be inquired in detail.

3 In addition to the medical history, signs, tests and other examination results closely related to the specialty, the admission medical records and admission records should also be noted for the non-undergraduate injuries and illnesses suffered by the patients and the diagnosis and treatment process. All non-healing injuries, regardless of the length of the medical history, should be included in the present medical history; Only those who have recovered or have not been ** for a long time can be included in the past medical history. In the list of diagnoses, the names of injuries and illnesses that are currently present and have not yet recovered should also be listed.

Patients who are transferred or readmitted to other hospitals should be treated as new patients. Those who are transferred from other departments should write the transfer-in. Those who are transferred from different wards or wards of the department only need to make necessary records and supplements in the course of the course of the disease.

4 Admission records and records should be completed as far as possible before the attending physician's visit the next morning, and within 24 hours after the patient's admission at the latest. If the patient is seriously ill and cannot complete the admission record within 24 hours, the detailed medical record must be completed in a timely manner; Admission records can be supplemented when circumstances permit. In the case of a large number of admissions, the chief physician shall set a time for completing the medical record at his discretion.

5 Except for obstetrics and a large number of patients with similar diseases admitted to the hospital, ** cannot be used to replace medical records; If you need to use ** medical records, you must get the approval of the superintendent.

6 The names and numbers of diseases diagnosed and operated on are based on the International Classification of Names of Diseases (latest edition) published by the International Health Organization (WHO) for statistical and analytical purposes. For the time being, the translation name used is subject to the English-Chinese Medical Glossary (published by the People's Medical Publishing House), and if there is no proper translation of the name of the disease and individual nouns, the original text or Latin can be used.

**Fainting caused by hypoglycemia Just write this.

Malnutrition, suspected to be caused by **.

Unless an allergen is identified, the general diagnosis is site-based, such as atopic dermatitis.