Medical record writing mode. Zhang XX, a 36-year-old female worker, was first diagnosed on September 8, 2002. 10 years ago, 1 baby was born naturally. After induced abortion two years ago, there were more leucorrhea and sometimes itching in the lower part of vagina. Two weeks ago, I had frequent urination, urgent urination and painful urination. At that time, I took norfloxacin and had a good rest. These two days, I came to see a doctor because of fatigue, aggravated symptoms, short and astringent urine frequency, prickling, low back pain, fever, chills, bitter taste, burning sensation in urine and dark yellow and turbid urine. Examination: t: 38.4℃, r: 18 times/min, p: 96 times/min, BP: 120/75 mmhg. Red tongue, yellow greasy fur and slippery pulse. Knocking pain in both kidneys, tenderness in the upper ureter of abdomen, no other positive signs found. Laboratory examination: urine routine showed a small amount of protein, white blood cells ++/Hp, red blood cells++/HP and white blood cell casts +/Lp. Blood routine showed that white blood cells were 12.7× 109/L and neutrophils were 84%. Urine bacterial culture interrupted by washing showed Escherichia coli, colony >; 105/ ml. Source: Exam reference answer: Hospitalization history Name: Zhang××××× Gender: Female source: Exam age: 36 years old Nationality: Han nationality marital status: married. Occupation: Worker's employment date: September 8, 2002. Medical history was collected on September 8, 2002. Main statement: frequent micturition, urgency, dysuria for 2 weeks, aggravated for 2 days, low back pain and fever. Current medical history: frequent micturition, urgent micturition and painful micturition occurred two weeks ago due to unclean vagina, but they got better after taking norfloxacin. Two days ago, I came to see a doctor because of fatigue, aggravated symptoms, short and astringent urine frequency, stinging drip, low back pain, fever, chills, bitter taste, burning sensation in urine and dark yellow and turbid urine. Symptoms: short and astringent urine, tingling, low back pain, fever, chills, bitter taste, burning sensation in urine, dark yellow and turbid urine. Source: Past history of examination: leucorrhea, sometimes itching in the lower part of vagina for 2 years. No other important medical history to carry. Resume: No record of special circumstances. Menstruation and marriage and childbearing history: menstrual history: 15. Married. 1 child, 10 years old. Abortion 1 time. Allergy history: no history of drug and food allergy. Source: extended family history: parents are alive, denying family history of hereditary diseases. Physical examination: T: 38.4℃ R: 18 beats/min P: 96 beats/min blood pressure: 120/75 mmHg source: check the overall situation: conscious, mentally acceptable, with a fever appearance, normal posture, clear language, no abnormal smell, red tongue, yellow greasy fur and slippery pulse. Skin mucosa and lymph nodes: the skin mucosa has no yellow spots, no macula and lymph node nuclei, and the superficial lymph nodes are not swollen. Head, face and neck: the hair is shiny, and there is no abnormality in eyes, ears, nose and mouth. The neck is not stiff, the trachea is centered, and there is no swelling and pain. Source: exam big chest: the chest is symmetrical and without deformity; Breathing sounds in both lungs are clear, and no dry and wet rales can be heard; The apical pulse and voiced boundary are normal, the heart rate is 96 beats/min, the rhythm is regular, and no murmur can be heard. Abdominal back: the abdomen is flat and soft, with tenderness at the upper point of ureter, no rebound pain and no lump; Liver and spleen failure, gallbladder tenderness (Murphy's sign negative). Both kidneys have percussion pain. Spine and limbs: the spine is free from deformity, rigidity and percussion pain, and the movement is not restricted; The limbs are normal and there is no edema. Before and after the yin, feces: before and after the yin is not checked (or no abnormality is found), and the urine is dark yellow and turbid (or no feces is found after the carving). Nervous system: No abnormality is found. Source: laboratory examination: urine routine showed a small amount of protein, white blood cells ++/Hp, red blood cells++/HP, white blood cell casts +/Lp. Blood routine showed that white blood cells were 12.7× 109/L and neutrophils were 84%. Urine bacterial culture interrupted by washing showed Escherichia coli, colony >; 105/ ml. Basis of disease differentiation and syndrome differentiation: It is known that the evil of dirty vagina invades the bladder, resulting in damp heat, improper vaporization of the bladder and impassable waterway, leading to stranguria, so frequent urination, urgency and pain can be seen clinically. Dampness and heat accumulate under the scorch, and the bladder gasification is out of control, so the urine is short and red, burning, and the drowning color is dark yellow and turbid; The waist is the home of the kidney, and the evil of damp-heat invades the kidney, so low back pain and knocking pain in the kidney area are seen; Damp heat is inherent, and evil is contending, so fever, chills and bitter taste are seen; Red tongue, yellow greasy fur and slippery pulse are all manifestations of damp-heat. Diagnostic basis of western medicine: 1. There are urinary system symptoms such as frequent urination, urgency, low back pain, dark yellow and turbid urine, as well as systemic symptoms such as fever and chills. 2. Signs: Body temperature reaches 38.4℃. Knocking pain in both kidneys, tenderness in the upper ureter of abdomen. 3. Laboratory examination: urine routine shows a small amount of protein, white blood cells ++/Hp, red blood cells++/HP, white blood cell casts +/Lp. Blood routine showed that white blood cells were 12.7× 109/L and neutrophils were 84%. Urine bacterial culture interrupted by washing showed Escherichia coli, colony >; 105/ ml. 4. Female, 36 years old, with a history of leucorrhea and itching, had a sudden onset. Admission diagnosis: Source: Exam TCM diagnosis: Tonglin western medicine diagnosis: acute pyelonephritis Source: Exam Dazhi: Qingre Lishi Tongluo prescription: Bazhengsan addition and subtraction: Xubian 15g Qumai 15g Akebia stem 5g Plantago 15g Talc 30g rhubarb 15g Shan Zhi/kloc-. 10g Scutellaria baicalensis Georgi 10g Cao5g decoction service signature: reference answer/s/blog _ 485db15f01009nto.html.