Position:home>Rehabilitation Case>The rehabilitation anamnesis of a medical university teacher
The rehabilitation anamnesis of a medical university teacher
From;  Author:Stand originally
Contract nephritic disease previously, I am the teacher of medical university, working property fostered me to save a habit goodly. Can you be? With respect to the medical record that obtains me, saying to go up is an an excellent work. The full name that the cover of anamnesis has written him well and truly, age, unit and Ceng Yin send the medicaments name of allergic reaction. The content of anamnesis fills in seriously by examined doctor. All assay sheet press time order ground of serious, whole orderly agent has been stuck, a little important auxiliary examination for example sheet of report of wire of CT, sternum, X also consults the time order of the examination is stuck on additionally one piece of paper. Translate the anamnesis data that the course arranges, can restrospect to the clue of go to a doctor of outpatient service of my first time. Check to the hospital every time, I can carry this anamnesis data that carries historical stigma, even if touch the doctor that goes up to contact me for the first time, saw these data also can be opposite my illness know sth like the palm of one's hand, from which I also benefit bandit is shallow. Above all, I do not relapse him give uncecessary details illness, was to avoid a lot of repetition to check next, more important is a doctor state of affairs of the happening that can understand my disease according to anamnesis account, development and to medicationed reaction circumstance, make more accurate diagnosis from which, choose more effective remedy.
Patient: Jiang Haitao, male, 28 years old, the Han nationality, married, college teacher, nanjing person, postcode: 210059, diagnose: Nephrosis is asked for integratedly, action in chief: Ache of double kidney area is unwell, face ministry reachs dropsy of double lower limbs 20 days. Examine system: T36.8 ℃ , p 80 second / cent, r 20 second / cent, BP 150/90mmHg; Assay: Total albumen 30g/L, albumin 16g/L, 20.16g/L of ration of albumen of 24 hours of make water, total cholesterol 8.3mmol/L, glycerine fat 2.5mmol/L, ASO () ;
After be admitted to hospital, give " immune answer kidney " the platoon poison of the law helps normal treatment cure and cure of Chinese and Western up to be handled to disease. Hospitalization 15 days, the eye is facial reach dropsy of double lower limbs to disappear, appetite increases, morpheus quality increases, many garrulous shape appears in make water sedimentary, uric color is deepened, uric flavour thicken. Cure checks 90 days: Blood pressure 130/80mmHg, 0.45g/L of ration of albumen of 24 hours of make water, total albumen 60g/L, albumin 30g/L, hematic fat also dropped. When leaving hospital, the patient says excitedly: "God, uric albumen turns shade, blood pressure also was stabilized. I must insist to use medical half an year, the nephritic structure that makes destroy is new repair rises, kidney function has restored, good my ill proper treatment. "

Previous12 Next