Vol 3 Chapter 2253: Harsh medical record writing

The patient's routine clinical examinations were fine, including imaging data. It would be impractical to do all the checks from beginning to end.
"What about bipolar disorder caused by changes in thyroid function?" Su Yun asked.
"In your words, there is still no way to explain Wang Can's existence." Zheng Ren continued to slide the mouse wheel little by little and carefully looked down at the big medical record.
Bipolar disorder is just one possibility, and Zheng Ren believes that it is unlikely.
"Boss, what do you look at the big medical record so carefully?" Su Yun asked.
"The medical record was written by Zhong Min, she is more meticulous." Zheng Ren said simply.
Clinicians write large medical records. When writing by hand, a standard large medical record took at least an hour.
Now that there are electronic medical records, many are options, which are much more convenient than handwritten medical records.
But because of this, many doctors by default will not look carefully and fill in carefully. After all, time is limited every day, there are too many things to do, and clinical staffing is not enough. It is enough to confuse unimportant places.
Zhong Min is a standard physician, because the former physicians did not go to the surgery, and it took a lot more time to write the medical records and see the patients than the surgeons.
In addition, her own personality is still delicate, especially after being scared once by the disappearance of the magic pen signature, it is even more serious and harsh.
When it comes to writing medical records, Zheng Ren thinks he can't keep up with Zhong Min, let alone Chang Yue.
"My eyes are reflecting light normally, and the conjunctiva is slightly yellow. Does this make sense, boss?" Su Yun asked.
The test sheet has been read. Examinations such as bilirubin are normal and can basically rule out jaundice.
In addition, hepatic encephalopathy may also cause mental symptoms, but the condition of the patient is far away from hepatic encephalopathy.
"A simple one is meaningless. The eye corners are red and swollen with a size of 1mm, accompanied by peeling." Zheng Ren subsequently saw another patient's signs described by Zhong Min.
Su Yun did not meet Zheng Ren, but sat down aside and watched Zheng Min's medical record with Zheng Ren very seriously.
Lin Yuan is very puzzled. Generally speaking, primary-level hospitals face the diagnosis and treatment of common diseases. Although she hasn't been to Haicheng, she thinks she should only do some minor surgery.
It is so pointless to describe the medical records in such a detailed way that it is like a realistic literary giant who uses a concise language to describe a passerby!
However, both Zheng and Yuner looked at the medical records silently. Lin Yuan had the illusion that he should have missed something.
At this moment, she seemed to feel a solemn atmosphere.
The conjunctiva and sclera are yellow, and the corners of the eyes are red and swollen. What is the problem?
She also began to watch the medical records with great concentration. Occasionally, Boss Zheng's hands would be paused for a moment, but the relevant places were only some common problems that were not worth paying attention to at all.
For example, pale lips, occasional gum bleeding, and so on.
What this medical record wrote ... Suddenly, Lin Yuan had a bad feeling.
She has seen the medical record of Sister Yue, which is more detailed than the medical record in front of her, and it can even be said that there is no detailed description.
I won't write my own medical records like this in the future!
She faintly sees her future dark. She doesn't want to sit in the office every day to write medical records. She wants to have surgery and become a world-renowned surgeon.
Nausea, no vomiting, progressive weight loss, weight loss of 2.3 kg within 1 year.
This description is too detailed, Lin Yuan's head hurts for a while.
Even Lin Yuan recalled that he had previously seen the doctor in Haicheng write about how the patient had oral ulcers and several ulcers.
The patient suspects a mental illness. What does it mean to write oral ulcers? !! Lin Yuan felt defamatory for a while.
Are the people under Boss Zheng's hands perverted? Writing a big medical record is so strict.
No, it's not strict. This can already be described as harsh.
Immediately, Lin Yuan saw the line of "3 months history of dietary changes" in the summary of the medical record. She had been speechless to the extreme, and if every medical record had to describe herself like this, she would rather go home in a few days.
"Su Yun, ask what is meant by Zhong Min's diet change." Zheng Ren suddenly said.
"Well, it is very clear. It is estimated that President Wang has never encountered a similar patient." Su Yun said softly, picking up the mobile phone, not looking for the phone book, and dialing a mobile phone number directly.
Clear? What is clear!
The cold hair on Lin Yuan's neck suddenly stood up.
How can it be clear, what exactly does Wang Can see when he sees it?
The corners of the eyes are red and swollen? Oral ulcer? Or a diet change.
For a moment, Lin Yuan had a sense of weakness in his heart. Things that I was once proud of collapsed so quickly in front of the two evildoers, Boss Zheng and Yun Geer, that it was so unacceptable.
"Zhong Min, you just wrote the medical record that Mr. Wang sent me just now."
"The patient's name is Han Cuijuan's medical record."
"See what you mean by a change in diet?"
"Okay, you and President Wang said, this is already a brow. After I discuss it with my boss, I will tell you the diagnosis immediately."
After speaking, Su Yun hung up the phone.
"Zhong Min said that the patient started to have heavy mouth three months ago and was eating too salty."
"Well, the diagnosis is very clear. Carbamazepine cannot be stopped, olanzapine 10 mg orally once a day. Vitamin B12 1 mg / d intramuscularly for the first 6 days, followed by 1 mg intramuscularly every week for the next 6 weeks, and then 1 mg intramuscularly every month. "Zheng Ren directly said treatment.
"Boss, it's too rigorous."
"A check is still to be done, is this necessary?"
"Still look for vitamin B12 and homocysteine." Su Yun asked.
"Well, the positive rate of blood vitamin B12 is not high, and homocysteine ​​must be checked." Zheng Rendao, "Check now, tell President Wang to wait for the results."
Lin Yuan watched Su Yun speechlessly and recalled the diagnostic criteria of vitamin B12 deficiency in his head.
"Boss Zheng, vitamin B12 deficiency is generally manifested as giant cell anemia, glossitis, and neuropsychiatric symptoms." Lin Yuan whispered.
"Well, there are some small details, not every patient with vitamin B12 deficiency will have glossitis and megaloblastic anemia." Zheng Rendao.
"..."
"For example, glossitis is the most common. It can be written diagnostically on inflammation of the mucous membranes of the tongue, mouth, and digestive tract. It is ideal to give patients a gastroscope if conditions permit."
"Ah?" Lin Yuan froze for a moment.
"Gastroscopy is most likely to show atrophy of the gastric mucosa, chronic inflammation, and intestinal manifestations in 50% -60% of biopsies."
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The patient's routine clinical examinations were fine, including imaging data. It would be impractical to do all the checks from beginning to end.
"What about bipolar disorder caused by changes in thyroid function?" Su Yun asked.
"In your words, there is still no way to explain Wang Can's existence." Zheng Ren continued to slide the mouse wheel little by little and carefully looked down at the big medical record.
Bipolar disorder is just one possibility, and Zheng Ren believes that it is unlikely.
"Boss, what do you look at the big medical record so carefully?" Su Yun asked.
"The medical record was written by Zhong Min, she is more meticulous." Zheng Ren said simply.
Clinicians write large medical records. When writing by hand, a standard large medical record took at least an hour.
Now that there are electronic medical records, many are options, which are much more convenient than handwritten medical records.
But because of this, many doctors by default will not look carefully and fill in carefully. After all, time is limited every day, there are too many things to do, and clinical staffing is not enough. It is enough to confuse unimportant places.
Zhong Min is a standard physician, because the former physicians did not go to the surgery, and it took a lot more time to write the medical records and see the patients than the surgeons.
In addition, her own personality is still delicate, especially after being scared once by the disappearance of the magic pen signature, it is even more serious and harsh.
When it comes to writing medical records, Zheng Ren thinks he can't keep up with Zhong Min, let alone Chang Yue.
"My eyes are reflecting light normally, and the conjunctiva is slightly yellow. Does this make sense, boss?" Su Yun asked.
The test sheet has been read. Examinations such as bilirubin are normal and can basically rule out jaundice.
In addition, hepatic encephalopathy may also cause mental symptoms, but the condition of the patient is far away from hepatic encephalopathy.
"A simple one is meaningless. The eye corners are red and swollen with a size of 1mm, accompanied by peeling." Zheng Ren subsequently saw another patient's signs described by Zhong Min.
Su Yun did not meet Zheng Ren, but sat down aside and watched Zheng Min's medical record with Zheng Ren very seriously.
Lin Yuan is very puzzled. Generally speaking, primary-level hospitals face the diagnosis and treatment of common diseases. Although she hasn't been to Haicheng, she thinks she should only do some minor surgery.
It is so pointless to describe the medical records in such a detailed way that it is like a realistic literary giant who uses a concise language to describe a passerby!
However, both Zheng and Yuner looked at the medical records silently. Lin Yuan had the illusion that he should have missed something.
At this moment, she seemed to feel a solemn atmosphere.
The conjunctiva and sclera are yellow, and the corners of the eyes are red and swollen. What is the problem?
She also began to watch the medical records with great concentration. Occasionally, Boss Zheng's hands would be paused for a moment, but the relevant places were only some common problems that were not worth paying attention to at all.
For example, pale lips, occasional gum bleeding, and so on.
What this medical record wrote ... Suddenly, Lin Yuan had a bad feeling.
She has seen the medical record of Sister Yue, which is more detailed than the medical record in front of her, and it can even be said that there is no detailed description.
I won't write my own medical records like this in the future!
She faintly sees her future dark. She doesn't want to sit in the office every day to write medical records. She wants to have surgery and become a world-renowned surgeon.
Nausea, no vomiting, progressive weight loss, weight loss of 2.3 kg within 1 year.
This description is too detailed, Lin Yuan's head hurts for a while.
Even Lin Yuan recalled that he had previously seen the doctor in Haicheng write about how the patient had oral ulcers and several ulcers.
The patient suspects a mental illness. What does it mean to write oral ulcers? !! Lin Yuan felt defamatory for a while.
Are the people under Boss Zheng's hands perverted? Writing a big medical record is so strict.
No, it's not strict. This can already be described as harsh.
Immediately, Lin Yuan saw the line of "3 months history of dietary changes" in the summary of the medical record. She had been speechless to the extreme, and if every medical record had to describe herself like this, she would rather go home in a few days.
"Su Yun, ask what is meant by Zhong Min's diet change." Zheng Ren suddenly said.
"Well, it is very clear. It is estimated that President Wang has never encountered a similar patient." Su Yun said softly, picking up the mobile phone, not looking for the phone book, and dialing a mobile phone number directly.
Clear? What is clear!
The cold hair on Lin Yuan's neck suddenly stood up.
How can it be clear, what exactly does Wang Can see when he sees it?
The corners of the eyes are red and swollen? Oral ulcer? Or a diet change.
For a moment, Lin Yuan had a sense of weakness in his heart. Things that I was once proud of collapsed so quickly in front of the two evildoers, Boss Zheng and Yun Geer, that it was so unacceptable.
"Zhong Min, you just wrote the medical record that Mr. Wang sent me just now."
"The patient's name is Han Cuijuan's medical record."
"See what you mean by a change in diet?"
"Okay, you and President Wang said that this side is already very eye-catching. Let me discuss it with my boss ~ EbookFREE.me ~ I will tell you the diagnosis immediately."
After speaking, Su Yun hung up the phone.
"Zhong Min said that the patient started to have heavy mouth three months ago and was eating too salty."
"Well, the diagnosis is very clear. Carbamazepine cannot be stopped, olanzapine 10 mg orally once a day. Vitamin B12 1 mg / d intramuscularly for the first 6 days, followed by 1 mg intramuscularly every week for the next 6 weeks, and then 1 mg intramuscularly every month. "Zheng Ren directly said treatment.
"Boss, it's too rigorous."
"A check is still to be done, is this necessary?"
"Still look for vitamin B12 and homocysteine." Su Yun asked.
"Well, the positive rate of blood vitamin B12 is not high, and homocysteine ​​must be checked." Zheng Rendao, "Check now, tell President Wang to wait for the results."
Lin Yuan watched Su Yun speechlessly and recalled the diagnostic criteria of vitamin B12 deficiency in his head.
"Boss Zheng, vitamin B12 deficiency is generally manifested as giant cell anemia, glossitis, and neuropsychiatric symptoms." Lin Yuan whispered.
"Well, there are some small details, not every patient with vitamin B12 deficiency will have glossitis and megaloblastic anemia." Zheng Rendao.
"..."
"For example, glossitis is the most common. It can be written diagnostically on inflammation of the mucous membranes of the tongue, mouth, and digestive tract. It is ideal to give patients a gastroscope if conditions permit."
"Ah?" Lin Yuan froze for a moment.
"Gastroscopy is most likely to show atrophy of the gastric mucosa, chronic inflammation, and intestinal manifestations in 50% -60% of biopsies."
Tips: press [Enter] to return to the directory, press (left key on the keyboard ←) to return to the previous chapter and press (right key on the keyboard →) to enter the next chapter